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The home care nurse is preparing a plan of care for a client diagnosed with Ménière's syndrome. Which nursing intervention should the nurse include to assist the client with controlling vertigo?
- A. Instruct the client to cut down on cigarette smoking.
- B. Encourage the client to increase the daily fluid intake.
- C. Encourage the client to avoid sudden head movements.
- D. Instruct the client to increase the amount of sodium in the diet.
Correct Answer: C
Rationale: Ménière's syndrome refers to dilation of the endolymphatic system by overproduction or decreased resorption of endolymphatic fluid. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Clients are advised to stop smoking because of its vasoconstrictive effects. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed.
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The nurse is caring for a postpartum client with thromboembolytic disease. Which intervention is most important to include when planning care to prevent the complication of pulmonary embolism?
- A. Enforce bed rest.
- B. Monitor the vital signs frequently.
- C. Assess the breath sounds frequently.
- D. Administer prescribed anticoagulant therapy.
Correct Answer: D
Rationale: The purposes of anticoagulant therapy for the treatment of thromboembolytic disease are to prevent the formation of a clot and to prevent a clot from moving to another area, thus preventing pulmonary embolism. Although the remaining options may be implemented for a client with thromboembolytic disease, the correct option will specifically assist in the prevention of pulmonary embolism.
A client is admitted to a mental health unit with a diagnosis of anorexia nervosa. When planning care for this client, which primary intervention should health promotion focus on?
- A. Providing a supportive environment
- B. Examining intrapsychic conflicts and past issues
- C. Emphasizing social interaction with clients who are withdrawn
- D. Helping the client identify and examine dysfunctional thoughts and beliefs
Correct Answer: D
Rationale: Health promotion focuses on helping clients identify and examine dysfunctional thoughts, as well as identifying and examining the values and beliefs that maintain these thoughts. Providing a supportive environment is important, but it is not as primary as option 4 for this client. Examining intrapsychic conflicts and past issues is not directly related to the client's problem. Emphasizing social interaction is not appropriate at this time.
A client hospitalized after a stroke is prepared for discharge. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. Which intervention should the home care nurse's plan include when planning for the client's care?
- A. Implements ROM exercises to the point of pain for the client
- B. Considers the use of active, passive, or active-assisted exercises in the home
- C. Encourages dependence on the home care nurse to complete the exercise program
- D. Develops a schedule involving ROM exercises every 3 hours during daylight hours
Correct Answer: B
Rationale: The home care nurse must consider all forms of ROM for the client. Even if the client has right hemiplegia, the client can assist with some of his or her own rehabilitative care. In addition, the goal of home care nursing is for the client to assume as much self-care and independence as possible. The nurse needs to teach so that the client becomes self-reliant. Options 1 and 4 are incorrect from a physiological standpoint.
The nurse plans care for a client with alcohol abuse disorder based on which support system?
- A. Fresh Start, is an option for families of addicts.
- B. Families Anonymous, an option for those addicted to nicotine.
- C. Al-Anon, an option for parents of children who abuse substances.
- D. Alcoholics Anonymous, a major self-help organization for the treatment of alcohol abuse.
Correct Answer: D
Rationale: Alcoholics Anonymous is a major self-help organization for the treatment of alcoholism. Option 1 is a group for families of alcoholics. Option 2 is for nicotine addicts. Option 3 is for the parents of children who abuse substances.
A client is experiencing diabetes insipidus as a result of cranial surgery. Which anticipated therapy should the nurse plan to implement?
- A. Fluid restriction
- B. Administering diuretics
- C. Increased sodium intake
- D. Intravenous (IV) replacement of fluid losses
Correct Answer: D
Rationale: The client with diabetes insipidus excretes large amounts of extremely dilute urine. This usually occurs as a result of decreased synthesis or the release of antidiuretic hormone in clients with conditions such as head injury, surgery near the hypothalamus, or increased intracranial pressure. Corrective measures include allowing ample oral fluid intake, administering IV fluid as needed to replace sensible and insensible losses, and administering vasopressin. Diuretics are not administered. Sodium is not administered because the serum sodium level is usually high, as is the serum osmolality.