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If the client develops lower abdominal pain after a cystoscopy, the nurse should instruct the client to do with following?
- A. Apply an ice pack to the pubic area.
- B. Massage the abdomen gently.
- C. Ambulate as much as possible.
- D. Sit in a tub of warm water.
Correct Answer: D
Rationale: Sitting in warm water can soothe bladder irritation and relax pelvic muscles, alleviating lower abdominal pain post-cystoscopy.
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Health maintenance and promotion activities are especially important for the older adult. Which of the following activities reflects the ability of chance activity for an otherwise healthy older adult?
- A. Drinks 1,500 mL of fluids per day.
- B. Consumes a balanced diet of 1,200 calories per day.
- C. Walks briskly for 10 minutes three times per week.
- D. Sleeps at least 8 hours each night.
Correct Answer: C
Rationale: Brisk walking promotes cardiovascular health and mobility. 1,500 mL fluid may be insufficient, 1,200 calories is too low for most, and 8 hours sleep is not activity-focused.
A 56-year-old client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which of the following symptoms indicates a toxic response to the chemotherapy?
- A. Decrease in appetite.
- B. Drowsiness.
- C. Spasms of the diaphragm.
- D. Cough and shortness of breath.
Correct Answer: D
Rationale: Cough and shortness of breath are hallmark symptoms of pulmonary toxicity, indicating potential lung damage from chemotherapy and requiring immediate attention.
The client has a nursing diagnosis of Self-care deficit related to the confinement of traction. Which of the following would indicate a successful outcome for this diagnosis?
- A. The client assists as much as possible in his care, demonstrating increased participation over time.
- B. The client allows the nurse to complete his care in an efficient manner without interfering.
- C. The client allows his wife to assume total responsibility for his care.
- D. The client allows his wife to complete his care to promote feelings of usefulness.
Correct Answer: A
Rationale: Increased participation in self-care indicates progress toward independence despite traction limitations.
Which of the following exercises should the nurse advise the client to avoid after a lumbar laminectomy?
- A. Knee-to-chest lifts.
- B. Hip tilts.
- C. Sit-ups.
- D. Pelvic tilts.
Correct Answer: C
Rationale: Sit-ups strain the surgical site and should be avoided to prevent injury post-laminectomy.
Nursing responsibilities for the client with a patient-controlled analgesia (PCA) system should include:
- A. Reassuring the client that pain will be relieved.
- B. Documenting the client's response to pain medication on a routine basis.
- C. Instructing the client to continue pressing the system's button whenever pain occurs.
- D. Titrating the client's pain medication until the client is free from pain.
Correct Answer: B
Rationale: Documenting the client's response to PCA is a key nursing responsibility to monitor efficacy and safety. Reassuring complete relief, instructing to press repeatedly, or titrating to pain-free status may be unrealistic or unsafe.