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The home care nurse visits a client who had a stroke (brain attack) with resultant unilateral neglect who was recently discharged from the hospital. Which instruction should the nurse provide to the family regarding care?
- A. Assist the client from the affected side.
- B. Place personal items directly in front of the client.
- C. Discourage the client from scanning the environment.
- D. Assist the client with grooming the unaffected side first.
Correct Answer: A
Rationale: Unilateral neglect involves a lack of awareness of the affected side. Assisting from the affected side helps focus the client's attention on it, promoting awareness. Initially, items are placed on the unaffected side, but gradually shifted. Scanning the environment is encouraged, and grooming the affected side first aids awareness.
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A client with a colostomy complains to the nurse of appliance odor. The nurse recommends that the client take in which deodorizing foods?
- A. Eggs
- B. Yogurt
- C. Cucumbers
- D. Mushrooms
Correct Answer: B
Rationale: Foods that help eliminate odor with a colostomy include yogurt, buttermilk, cranberry juice, and parsley. Foods that cause odor are many and include alcohol, beans, turnips, radishes, asparagus, onions, cucumbers, mushrooms, cabbage, eggs, and fish.
The nurse is monitoring fetal heart rate (FHR) on a laboring client. Which finding should be reported to the health care provider?
- A. FHR of 154 bpm with moderate variability
- B. FHR of 114 bpm with moderate variability
- C. FHR of 170 bpm lasting more than 10 minutes
- D. FHR of 156 bpm with minimal variability in a premature infant
Correct Answer: C
Rationale: FHR of 170 bpm for over 10 minutes indicates tachycardia, requiring immediate reporting. Other findings are within normal or less urgent ranges.
The nurse is preparing a client diagnosed with pneumonia for discharge. Which statement by the client should alert the nurse to the fact that the client needs further teaching before being discharged?
- A. I will take all of my antibiotics, even if I do feel 100% better.
- B. You can toss out that incentive spirometer as soon as I leave for home.
- C. I realize that it may be weeks before my usual sense of well-being returns.
- D. It is a good idea for me to take a nap every afternoon for the next couple of weeks.
Correct Answer: B
Rationale: Deep breathing and coughing exercises and the use of incentive spirometry should be practiced for 6 to 8 weeks after the client diagnosed with pneumonia is discharged from the hospital to keep the alveoli expanded and promote the removal of lung secretions. If the entire regimen of antibiotics is not taken, the client may suffer a relapse. The period of convalescence with pneumonia is often lengthy, and it may be weeks before the client feels a sense of well-being. Adequate rest is needed to maintain progress toward recovery.
A child with a diagnosis of umbilical hernia has been scheduled for surgical repair in 2 weeks. The clinic nurse instructs the parents about the signs of possible hernia strangulation. The nurse tells the parents that which sign requires primary health care provider notification?
- A. Fever
- B. Diarrhea
- C. Vomiting
- D. Constipation
Correct Answer: C
Rationale: The parents of a child with an umbilical hernia need to be instructed regarding the signs/symptoms of strangulation, which include vomiting, pain, and an irreducible mass at the umbilicus. Fever, diarrhea, and constipation are not signs of hernia strangulation. The parents should be instructed to contact the primary health care provider immediately if strangulation is suspected.
The nurse is teaching a client who had been newly diagnosed with diabetes mellitus about blood glucose monitoring. The nurse should teach the client to report glucose levels that consistently exceed which level?
- A. 150 mg/dL (8.57 mmol/L)
- B. 200 mg/dL (11.42 mmol/L)
- C. 250 mg/dL (14.28 mmol/L)
- D. 350 mg/dL (20.0 mmol/L)
Correct Answer: C
Rationale: The normal blood glucose level ranges from 70 to 110 mg/dL (4 to 6 mmol/L), or as designated and preferred by the primary health care provider. The client with diabetes mellitus should be taught to report blood glucose levels that exceed 250 mg/dL (14.28 mmol/L), unless otherwise instructed by the primary health care provider. Options 1 and 2 are high levels but do not require primary health care provider notification. Option 4 is a high value; the client should report an elevated level before it reaches this point.