Nokea
The client with peripheral vascular disease is reviewing self-care measures. Which of the following statements indicates proper self-care measures?
- A. "I like to soak my feet in the hot tub every day."?
- B. "I walk to the mailbox in my bare feet."?
- C. "I stopped smoking and only use chewing tobacco."?
- D. "I have my wife examine the soles of my feet each day."?
Correct Answer: D
Rationale: The correct answer is, "I have my wife examine the soles of my feet each day."? Clients with peripheral vascular disease should examine their feet daily for any signs of redness, dryness, or cuts. If the client is unable to do this themselves due to decreased sensation in their feet, a caregiver or family member should assist. Soaking feet in a hot tub should be avoided as the client may not be able to sense if the water is too hot, potentially causing burns. Walking barefoot can lead to injuries, so wearing shoes or slippers is recommended to minimize trauma. While quitting smoking is a positive step, using chewing tobacco can still constrict blood vessels, adversely affecting circulation in the extremities.
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Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?
- A. The clothing may be potential evidence with legal implications.
- B. Such care facilitates the preservation of potential evidence.
- C. The clothing of a trauma victim can be used for further investigation.
- D. Such care maintains the integrity of the clothing for forensic analysis.
Correct Answer: C
Rationale: In cases of trauma, the clothing of a client can hold crucial evidence that may have legal implications. It is essential for the nurse to avoid cutting through or disrupting any tears, holes, bloodstains, or dirt present on the clothing to preserve this potential evidence. The correct answer highlights the legal importance of preserving the clothing for potential legal implications. Choice B is related but does not emphasize the legal aspect explicitly. Choice C is vague in mentioning further investigation without specifying the legal significance. Choice D focuses more on forensic analysis rather than the legal implications of preserving the clothing.
Which type of exercises might be prescribed to strengthen the pelvic floor muscles of a client with urinary incontinence?
- A. Kegel
- B. resistance
- C. passive
- D. stretching
Correct Answer: A
Rationale: The correct answer is Kegel. Kegel exercises are specifically designed to strengthen the pelvic floor muscles, making them an effective treatment for urinary incontinence. These exercises involve contracting and relaxing the pelvic floor muscles, which helps to improve muscle tone and control. Choice B, resistance exercises, may not directly target the pelvic floor muscles as effectively as Kegel exercises. Passive exercises (Choice C) do not actively engage the muscles and are unlikely to strengthen the pelvic floor. Stretching exercises (Choice D) focus on increasing flexibility rather than muscle strength, so they are not the most appropriate for strengthening the pelvic floor muscles in the context of urinary incontinence.
What advice should be given to a client with stress incontinence?
- A. to consider trying Kegel exercises
- B. to undergo surgery immediately
- C. to avoid all forms of treatment
- D. to ignore the issue as it is not serious
Correct Answer: A
Rationale: For stress incontinence, advising the client to consider trying Kegel exercises is appropriate. Kegel exercises involve tightening and releasing the pelvic floor muscles, which can improve stress incontinence by strengthening the muscles that control urination. Choice B suggesting immediate surgery is incorrect as surgery is usually considered after conservative treatments like Kegel exercises have been tried. Choice C advising to avoid all forms of treatment is dangerous and neglectful. Choice D recommending to ignore the issue is inappropriate as it can impact the client's quality of life and may worsen over time without intervention.
Which of the following nursing diagnoses is most appropriate for the client experiencing acute pancreatitis?
- A. Confusion
- B. Latex Allergy
- C. Acute Pain
- D. Constipation
Correct Answer: C
Rationale: Acute Pain is the most appropriate nursing diagnosis for a client experiencing acute pancreatitis because it is a common symptom associated with this condition. Pancreatitis often presents with severe abdominal pain that may radiate to the back. Confusion, Latex Allergy, and Constipation are not typically associated with acute pancreatitis. Confusion may occur in severe cases of pancreatitis with complications, but acute pain is the priority nursing diagnosis due to its prevalence and impact on the client's well-being.
What are the side effects of first-generation over-the-counter (OTC) antihistamines like diphenhydramine (Benadryl) and hydroxyzine (Atarax) in infants and children?
- A. Reye's syndrome.
- B. cholinergic effects.
- C. paradoxical CNS stimulation.
- D. nausea and diarrhea.
Correct Answer: C
Rationale: The correct answer is paradoxical CNS stimulation. First-generation OTC antihistamines, such as diphenhydramine and hydroxyzine, can lead to paradoxical CNS stimulation in infants and children. This phenomenon is characterized by symptoms like excitement, euphoria, restlessness, and confusion, rather than the expected sedative effect. Due to this unexpected response, these antihistamines are used less frequently in pediatric populations. Reye's syndrome is a rare systemic response to a virus and is not a side effect of antihistamines. First-generation OTC antihistamines do not typically exhibit cholinergic effects. Nausea and diarrhea are uncommon side effects of these antihistamines and are less commonly observed than paradoxical CNS stimulation.