Nokea
The home care nurse has given instructions to a client who was recently discharged from the hospital regarding the care of an arterial ischemic leg ulcer. The nurse determines that there is a need for further teaching if the client makes which statement?
- A. I should inspect my feet daily.
- B. I should wear shoes and socks.
- C. I should cut my toenails straight across.
- D. I should raise my legs above the level of my heart periodically.
Correct Answer: D
Rationale: Raising legs above heart level is inappropriate for arterial ischemic ulcers, as it reduces blood flow to the extremities, worsening ischemia. Daily foot inspection, wearing shoes and socks, and cutting toenails straight across are correct care measures.
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A client has urinary calculi that are composed of uric acid, and the nurse teaches the client dietary measures to prevent the further development of the calculi. The nurse determines that the client understands the dietary measures if the client states that it is necessary to avoid consuming what food products?
- A. Milk
- B. Yogurt
- C. Spinach, chocolate, and tea
- D. Sardines, herring, and organ meats
Correct Answer: D
Rationale: The client diagnosed with a uric acid stone should limit the intake of foods that are high in purines. Organ meats, sardines, herring, and other high-purine foods are eliminated from the diet. Foods with moderate levels of purines, such as red and white meats and some seafood, are also limited. Milk, yogurt, spinach, chocolate, and tea are recommended dietary changes to prevent calculi that are composed of calcium phosphate or calcium oxalate.
The home care nurse visits a client who was recently diagnosed with cirrhosis and provides home care management instructions to the client. Which statement by the client indicates the need for further teaching?
- A. I will obtain adequate rest.
- B. I should monitor my weight regularly.
- C. I will take Tylenol if I get a headache.
- D. I should include sufficient carbohydrates in my diet.
Correct Answer: C
Rationale: Cirrhosis is a chronic liver disease, and acetaminophen (Tylenol) should be avoided because it can cause fatal liver damage in clients with cirrhosis. Adequate rest, regular weight monitoring, and sufficient carbohydrate intake (2000 to 3000 calories daily) are appropriate for managing cirrhosis.
The nurse is teaching a client with acute kidney injury to include proteins in the diet that are considered high quality or complete proteins. The nurse determines that the client needs further teaching if he indicates that which food item is considered high quality?
- A. Fish
- B. Eggs
- C. Chicken
- D. Broccoli
Correct Answer: D
Rationale: High-quality or complete proteins, which contain essential amino acids, come from animal sources like fish, eggs, and chicken. Broccoli, a plant-based source, provides low-quality or incomplete proteins, indicating the client's misunderstanding.
The nurse provides discharge teaching to a client after a vasectomy. Which statement by the client indicates the need for further teaching?
- A. I can use a scrotal support if I need to.'
- B. I don't need to practice birth control any longer.'
- C. I can resume sexual intercourse whenever I want.'
- D. I can use an ice bag and take an analgesic for pain or swelling.'
Correct Answer: B
Rationale: After vasectomy, the client must continue to practice a method of birth control until the follow-up semen analysis shows azoospermia. Live sperm may be present in the vas deferens after this procedure. Using scrotal support, resuming sexual activity, and promoting pain relief with ice and taking an analgesic such as acetaminophen are appropriate client statements.
A clinic nurse providing home care instructions to an adolescent diagnosed with iron deficiency anemia concentrates on the administration of oral iron preparations. The nurse should tell the adolescent that it is best to take the iron with which liquid?
- A. Cola
- B. Soda
- C. Water
- D. Tomato juice
Correct Answer: D
Rationale: Iron should be administered with vitamin C-rich fluids because vitamin \mathrm{C enhances the absorption of the iron preparation. Tomato juice has a high ascorbic acid (vitamin C) content, whereas cola, soda, and water do not contain vitamin C.