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The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
- A. Teaching the client to report a nosebleed
- B. Instructing the client to maintain strict bed rest
- C. Telling the client to notify the doctor of pedal edema
- D. Advising the client to avoid sodium sources in the diet
Correct Answer: A
Rationale: Nosebleeds in preeclampsia may indicate severe hypertension or coagulopathy, requiring immediate reporting. Pedal edema is common, bed rest is not always needed, and sodium restriction is secondary.
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A client with a history of a thyroidectomy is being discharged. The nurse should teach the client to:
- A. Monitor for signs of hyperthyroidism
- B. Avoid calcium-rich foods
- C. Take the medication at bedtime
- D. Report muscle twitching
Correct Answer: D
Rationale: Muscle twitching post-thyroidectomy may indicate hypocalcemia from parathyroid damage, requiring immediate reporting. Hyperthyroidism, calcium foods, and bedtime dosing are not primary concerns.
The physician has ordered a low-residue diet for a client with Crohn's disease. Which food is not permitted in a low-residue diet?
- A. Mashed potatoes
- B. Smooth peanut butter
- C. Fried fish
- D. Rice
Correct Answer: C
Rationale: A low-residue diet minimizes fiber and irritating foods; fried fish is high in fat and can irritate the gut, making it unsuitable for Crohn's disease.
Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication?
- A. I would notify my physician immediately if I experience nausea, vomiting, and double vision.'
- B. I could stop taking this medication when I begin to feel better.'
- C. I should only take the medication if my heart rate is greater than 100 bpm.'
- D. I should always take this medication with an antacid.'
Correct Answer: A
Rationale: The first signs of digoxin toxicity include abdominal pain, anorexia, nausea, vomiting, and visual disturbances. The physician should be notified if any of these symptoms are experienced. The positive inotropic effects of digoxin increase cardiac output and result in an enhanced activity tolerance. 'Feeling better' indicates the drug is working and medication therapy must be continued. Clients should be taught to take their pulse prior to taking the digoxin. If their pulse rate becomes irregular, slows significantly, or is >100 bpm the physician should be notified. Antacids decrease the effectiveness of digoxin.
The mother of a six-year-old with autistic disorder tells the nurse that her son has been much more difficult to care for since the birth of his sister. The best explanation for changes in the child's behavior is:
- A. The child did not want a sibling.
- B. The child was not adequately prepared for the baby's arrival.
- C. The child's daily routine has been upset by the birth of his sister.
- D. The child is just trying to get the parent's attention.
Correct Answer: C
Rationale: Children with autism often rely on structured routines, and disruptions, such as a new sibling, can lead to behavioral changes due to difficulty adapting to change.
A client arrives in the emergency room with severe burns of the hands, right arm, face, and neck. The nurse needs to start an IV.
- A. Top of client's right hand
- B. Left antecubital fossa
- C. Top of either foot
- D. Left forearm
Correct Answer: B
Rationale: The left antecubital fossa is suitable for IV placement, avoiding burned areas (right hand, arm, face, neck). The foot (C) is less ideal due to infection risk, and the left forearm (D) may be too close to burn sites.