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The husband and adult children of a woman who abuses alcohol ask the nurse what approach to use when her drinking behavior disrupts family plans. Which response is best for the nurse to provide?
- A. Destroy any hidden supplies of alcohol she has at home so she has to stay sober
- B. When she drinks, communicate how disruptive her behaviors are and the burden they inflict on the family
- C. Make her responsible for the consequences of her drinking behaviors
- D. Include her in family activities whether she is drinking or sober
Correct Answer: C
Rationale: The best approach for the nurse to suggest is to make the woman responsible for the consequences of her drinking behaviors. By holding her accountable, she is more likely to recognize the impact of her actions and potentially initiate change. Destroying hidden alcohol supplies (Choice A) might lead to conflict and further secretive behavior. Simply communicating the disruptions caused by her drinking (Choice B) may not effectively address the issue. Including her in family activities regardless of her drinking status (Choice D) could enable the behavior and not address the underlying problem.
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The healthcare provider prescribes a diet high in vitamin C for a client with a leg wound. Which food should the nurse encourage the client to eat?
- A. Bananas and pineapple
- B. Cottage cheese and crackers
- C. Peanut butter and jelly
- D. Tomato and lettuce salad
Correct Answer: D
Rationale: Tomatoes and lettuce are high in vitamin C, making them suitable choices for a diet prescribed for wound healing. Bananas and pineapple (Choice A) are not particularly high in vitamin C compared to tomatoes and lettuce. Cottage cheese and crackers (Choice B) as well as peanut butter and jelly (Choice C) do not provide significant amounts of vitamin C, which is essential for wound healing.
A nurse is planning care for a client who is at risk for developing deep vein thrombosis (DVT). Which intervention should the nurse include in this client's plan of care?
- A. Maintain the client on bed rest
- B. Apply warm, moist compresses to the legs
- C. Encourage early ambulation
- D. Massage the legs daily
Correct Answer: C
Rationale: The correct intervention for a client at risk for developing deep vein thrombosis (DVT) is to encourage early ambulation. Early ambulation helps prevent DVT by promoting circulation, reducing stasis, and preventing blood clot formation. Maintaining the client on bed rest (Choice A) would increase the risk of DVT due to decreased mobility. Applying warm, moist compresses to the legs (Choice B) can be beneficial for other conditions but does not directly prevent DVT. Massaging the legs daily (Choice D) can dislodge a blood clot, leading to serious complications in a client at risk for DVT.
The nurse is caring for a client who is 2 days post-op following an abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?
- A. Apply a sterile saline dressing to the wound
- B. Notify the healthcare provider
- C. Administer pain medication
- D. Cover the wound with an abdominal binder
Correct Answer: A
Rationale: In this situation, the priority action for the nurse is to apply a sterile saline dressing to the wound. This helps prevent infection and keeps the wound moist, which is crucial in promoting healing and preventing further complications. Option B, notifying the healthcare provider, is important but should come after addressing the wound. Administering pain medication (Option C) may be necessary but is not the first action to take in this emergency situation. Covering the wound with an abdominal binder (Option D) is not appropriate and may cause further harm by applying pressure to the protruding bowel.
The client is being taught how to take alendronate (Fosamax) for osteoporosis treatment. Which statement indicates that the client needs further teaching?
- A. I should take this medication at bedtime
- B. I will need to take this medication for at least 3 years
- C. I should sit up for 30 minutes after taking the medication
- D. I should take this medication with a full glass of water
Correct Answer: A
Rationale: The correct answer is A because taking Fosamax at bedtime is incorrect. It should be taken in the morning with a full glass of water to prevent esophageal irritation. Choice B is correct; alendronate is typically taken for several years to treat osteoporosis. Choice C is correct as remaining upright for 30 minutes after taking Fosamax helps prevent esophageal irritation. Choice D is also correct as taking alendronate with a full glass of water is necessary to ensure proper absorption.
While teaching a group of adults about health promotion activities, a nurse identifies a behavior that poses the most significant risk factor for the development of skin cancer. Which behavior should the nurse address?
- A. Consuming a high-fat diet
- B. Using tanning beds
- C. Smoking cigarettes
- D. Drinking alcohol
Correct Answer: B
Rationale: Using tanning beds is the most significant risk factor for developing skin cancer. Ultraviolet (UV) radiation from tanning beds damages the skin and increases the risk of skin cancer. Consuming a high-fat diet, smoking cigarettes, and drinking alcohol are unhealthy behaviors but are not directly linked to the development of skin cancer like UV exposure from tanning beds.