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An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?
- A. Demonstrate the use of visual scanning during meals to the client and family.
- B. Explain that weight loss will be reversed after the acute phase of the stroke has ended.
- C. Suggest that the family bring foods from home that the client enjoys eating.
- D. Encourage the family to offer to feed the client when she does not eat her entire meal.
Correct Answer: A
Rationale: Teaching visual scanning compensates for visual perception deficits post-CVA, enabling the client to see all food on the tray, addressing the root cause of poor intake and improving nutrition.
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The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?
- A. Wears clothing to cover the radiation site.
- B. Washes the radiation site with antibacterial soap and water.
- C. Applies prescribed lotions to the radiation site.
- D. Dries the area with patting motions after taking a shower.
Correct Answer: B
Rationale: Washing with antibacterial soap can dry and irritate the sensitive skin at the radiation site, increasing the risk of damage. Mild, unscented soap is recommended, indicating a need for further teaching.
A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?
- A. Confirmation of the autoimmune disease process.
- B. Evidence of spread of the disease to the kidneys.
- C. Indication of the onset of joint degeneration.
- D. Representative of a decline in the client's condition.
Correct Answer: A
Rationale: Elevated rheumatoid factor is a marker of the autoimmune process in rheumatoid arthritis, confirming the diagnosis and indicating disease severity, not specific organ involvement or decline.
An adult client, a smoker, has had chronic obstructive pulmonary disease (COPD) for twelve years. When conducting discharge teaching, what should the nurse advise the client to avoid in order to prevent exacerbation of COPD?
- A. Exposure to persons with pneumonia or chickenpox.
- B. Excessive physical exertion and respiratory tract infections.
- C. Overdose of albuterol and alcohol consumption.
- D. Excessive bedrest and lack of exercise.
Correct Answer: B
Rationale: Excessive physical exertion and respiratory infections are primary triggers for COPD exacerbation, increasing oxygen demand and causing airway inflammation, which the client should avoid.
A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?
- A. Begin a weight loss program.
- B. Drink 1 to 2 glasses of wine at bedtime.
- C. Take sedatives prior to sleep.
- D. Sleep with the head of the bed flat.
Correct Answer: A
Rationale: Weight loss can reduce fat deposits around the neck and throat, improving airflow and decreasing the severity of OSA, making it an effective alternative or complementary strategy to CPAP.
The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?
- A. Cleanse the tongue and mouth with swabs.
- B. Administer a topical analgesic per protocol.
- C. Obtain a soft diet for the client.
- D. Encourage frequent mouth care.
Correct Answer: B
Rationale: Administering a topical analgesic provides immediate pain relief for mucositis, addressing the client's discomfort first before implementing other supportive measures like diet or mouth care.