Nokea
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.
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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 nurse is preparing staff education on the developmental stages and milestones in a normally developing fetus. Which information should be included?
- A. The testes at the inguinal ring descend to scrotum at 12 weeks.
- B. The bladder and urethra separate from the rectum at 12 weeks.
- C. The kidneys are in position at 16 weeks with typical shape and plan.
- D. The nostrils reopen and primitive respiratory-like movement begins at 24 weeks.
Correct Answer: C
Rationale: Kidneys reach their position by 16 weeks. Testicular descent occurs later (28-32 weeks), bladder-urethra separation by 8 weeks, and respiratory movements by 20-24 weeks.
A teenager returns to the gynecological clinic for a follow-up visit for a sexually transmitted infection (STI). Which statement by the teenager indicates the need for further teaching?
- A. I know you won't tell my parents I'm sick.
- B. I finished all of the antibiotics, just like you said.
- C. I always make sure that my boyfriend uses a condom.
- D. My boyfriend doesn't have to come in for treatment, does he?
Correct Answer: D
Rationale: When treating STIs, all sexual contacts must be contacted and treated with medication. The treatment of a teenager for an STI is confidential, and parents will not be contacted, even if the client is less than 18 years old. Clients should always finish the course of antibiotics prescribed by the primary health care provider. Clients should always use a condom with any sexual contact.
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.
The nurse has been preparing a client diagnosed with chronic obstructive pulmonary disease for discharge. Which statement by the client indicates the need for further teaching about nutrition?
- A. I will rest a few minutes before I eat.
- B. I will not eat as much cabbage as I once did.
- C. I will certainly try to drink 3 L of fluid every day.
- D. It's best to eat three large meals a day, so that I will get all my nutrients.
Correct Answer: D
Rationale: Large meals distend the abdomen and elevate the diaphragm, which may interfere with breathing for the client diagnosed with chronic obstructive pulmonary disease. Resting before eating may decrease the fatigue that is often associated with chronic obstructive pulmonary disease. Gas-forming foods may cause bloating, which interferes with normal diaphragmatic breathing. Adequate fluid intake helps liquefy pulmonary secretions.