A client with stage-four Parkinson's disease.
In developing discharge plans with the family of the client with stage-four Parkinson's disease, it is MOST important for the nurse to include which of the following activities?
- A. Ambulate twice daily.
- B. ROM exercise to all extremities four times a day.
- C. Include activities such as knitting and putting puzzles together.
- D. Encourage and provide writing materials.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client would be unable to ambulate (2) correct-in stage four Parkinson's disease, client is immobile (3) client cannot perform activities that require small-muscle dexterity (4) client cannot perform activities that require small-muscle dexterity
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Which laboratory test conducted on the client with diabetes mellitus indicates compliance?
- A. Fasting blood glucose
- B. Two-hour post-prandial
- C. Hgb A-1C
- D. Dextrostix
Correct Answer: C
Rationale: Hgb A-1C reflects average blood glucose over 2-3 months, indicating long-term compliance. Options A, B, and D provide short-term snapshots and are less reliable for compliance.
The nurse is teaching a client with a new diagnosis of heart failure about furosemide (Lasix). Which of the following statements by the client indicates a need for further teaching?
- A. I should report muscle cramps to my doctor.
- B. I should take this medication in the morning.
- C. I should eat foods high in potassium.
- D. I should stop this medication if I feel better.
Correct Answer: D
Rationale: Stopping furosemide when feeling better is incorrect, as heart failure requires lifelong treatment to manage fluid overload. Options A, B, and C are correct: muscle cramps may indicate hypokalemia, morning dosing minimizes nocturia, and potassium-rich foods are recommended.
A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure
- A. right heart function
- B. left heart function
- C. renal tubule function
- D. carotid artery function
Correct Answer: B
Rationale: left heart function. The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. It can provide hemodynamic information such as intracardiac pressure readings and oxygen saturation data, and even transvenous pacing. Information about left ventricular function is important because it directly affects tissue perfusion. Right-sided heart function is assessed through the evaluation of the central venous pressure (CVP).
The nurse is administering alendronate (Fosamax) to an adult. Which instruction is necessary to give the client?
- A. Take medication with milk and a snack.
- B. Take medication after each meal.
- C. Sit up for at least 30 minutes after taking medication.
- D. Lie down for 30 minutes after taking medication.
Correct Answer: C
Rationale: Alendronate can cause esophageal irritation; sitting up for 30 minutes post-dose ensures proper passage and absorption, preventing reflux. Milk, meals, or lying down increase irritation risk.
A terminally ill client says to the nurse, 'Do you believe in heaven?' How should the nurse respond?
- A. Yes, I believe in heaven and hell.'
- B. My personal belief is private.'
- C. Do you believe in heaven?'
- D. Do you want to see your clergyman?'
Correct Answer: C
Rationale: Reflecting the question back encourages the client to share beliefs, fostering spiritual discussion. Sharing personal beliefs, withholding, or redirecting are less therapeutic.
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