Nokea
The client with a laryngectomy is being discharged. The nurse should determine that the client understands to do which of the following self-care measures? Select all that apply.
- A. Provide humidification in the home.
- B. Use a protective shield over the stoma for bathing.
- C. Consume a liberal intake of fluids (2 to 3 L/day).
- D. Limit spicy seasonings on food.
- E. Follow a low-fiber diet.
Correct Answer: A,B,C
Rationale: Self-care measures include home humidification to keep the airway moist, using a stoma shield during bathing to prevent water entry, and consuming 2-3 L/day of fluids to maintain hydration. Spicy foods and low-fiber diets are not typically restricted.
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A 10-year-old client is diagnosed with infectious mononucleosis. Her white blood cell (WBC) count is 19,000/µL. She has a streptococcal throat infection and her spleen is enlarged. She has aching muscles. Which of the following instructions should the nurse include in discharge planning with the client and the essential caregiver? Select all that apply.
- A. Stay on bed rest until the temperature is normal.
- B. Gargle with warm saline while the throat is irritated.
- C. Increase intake of fluids until the infection subsides.
- D. Take aspirin as long as the fever and myalgia persist.
- E. Avoid contact sports while the spleen is enlarged.
Correct Answer: B,C,E
Rationale: Infectious mononucleosis with an enlarged spleen requires avoiding contact sports to prevent splenic rupture, a serious complication. Gargling with warm saline soothes the throat, and increased fluids support recovery and prevent dehydration. Bed rest is not strictly necessary unless fever persists, and aspirin should be avoided in children due to the risk of Reye's syndrome.
Which of the following groups would benefit most from education regarding potential risk factors for melanoma?
- A. Adults older than age 35.
- B. Senior citizens who have been repeatedly exposed to the effects of ultraviolet A and ultraviolet B rays.
- C. Parents with children.
- D. Employees of a chemical factory.
Correct Answer: B
Rationale: Senior citizens with repeated exposure to UV rays are at the highest risk for melanoma due to cumulative skin damage. Education on risk factors like UV exposure is most beneficial for this group.
The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 5 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
Click to highlight the orders that the nurse should consider a priority.
- A. Perform admission medication reconciliation and admit the client to the intensive care unit
- B. Remove the client's clothing
- C. Start a large-bore peripheral vascular access device
- D. 0.9% sodium chloride (normal saline) 1000 mL, IV, once
- E. Obtain medical records from the client's outpatient primary healthcare provider
- F. Insert temperature-sensing indwelling urinary catheter
- G. Apply a cooling blanket to the client
Correct Answer: B,C,D,F,G
Rationale: Priority orders address immediate life-threatening issues: removing clothing (B), IV access (C), saline (D), temperature catheter (F), and cooling blanket (G) manage heat stroke and hypotension. Medication reconciliation (A) and medical records (E) are secondary.
The nurse should include which of the following instructions in the teaching plan for a client with chronic sinusitis?
- A. Avoid the use of caffeinated beverages.
- B. Perform postural drainage every day.
- C. Take hot showers twice daily.
- D. Report a temperature of 102°F (38.9°C) or higher.
Correct Answer: C,D
Rationale: Hot showers help moisten nasal passages and promote sinus drainage, relieving symptoms of chronic sinusitis. Reporting a high fever is critical as it may indicate a worsening infection requiring medical attention. Caffeine restriction is not typically necessary. Postural drainage is more relevant for lung conditions like bronchiectasis.
The client tells the nurse that since his diagnosis of stomach cancer, he has been having trouble sleeping and is frequently preoccupied with thoughts about how his life will change. He says, 'I wish my life could stay the same.' Based on this information, which one of the following nursing diagnoses would be appropriate at this time?
- A. Ineffective coping related to the diagnosis of cancer.
- B. Insomnia related to fear of the unknown.
- C. Grieving related to the diagnosis of cancer.
- D. Anxiety related to the need for gastric surgery.
Correct Answer: C
Rationale: The client's statement and symptoms suggest grieving related to the life-altering diagnosis of stomach cancer. This diagnosis best captures the emotional response to the anticipated changes.