Nokea
The nurse has completed discharge teaching with the parents of a child diagnosed with glomerulonephritis. Which statement by the parents indicates that further teaching is necessary?
- A. We'll check our child's blood pressure every day.
- B. We'll test our child's urine for albumin every week.
- C. It'll be so good to have our child back in tap-dancing classes next week.
- D. We'll be sure that our child eats a lot of vegetables and does not add extra salt to food.
Correct Answer: C
Rationale: Tap dancing classes 1 week after discharge would be unrealistic and involve a too rapid increase in activity. Glomerulonephritis results in destruction, inflammation, and sclerosis of the glomeruli of the kidneys. After discharge, parents should allow the child to return to his or her normal routine and activities, with adequate periods allowed for rest. Taking daily blood pressure, testing urine weekly for albumin, and restricting extra sodium are appropriate home care measures.
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The nurse is participating in a free community health screening with a group of student nurses. Which statement by a student nurse requires further teaching by the licensed nurse?
- A. Colorectal cancer screening should begin at age 50.
- B. Men should have a prostate-specific antigen test starting at age 55.
- C. High-density lipoprotein should be greater than 50 mg/dL for women.
- D. Risk factors for hypertension include being over age 60 and leading a sedentary lifestyle.
Correct Answer: B
Rationale: Prostate-specific antigen testing typically starts at age 50, not 55, for average-risk men. Other statements are accurate.
The clinic nurse is providing instructions to a client in the third trimester of pregnancy regarding relief measures for heartburn. Which instruction should the nurse provide to the client?
- A. Sip on milk or hot tea.
- B. Use antacids that contain sodium.
- C. Eat fatty foods once a day in the morning only.
- D. Eat three large meals a day rather than small, frequent meals.
Correct Answer: A
Rationale: Sipping on milk or hot tea can soothe the gastrointestinal tract and relieve heartburn. Antacids containing sodium should be avoided to prevent edema. Fatty foods should be avoided entirely, and small, frequent meals are recommended to reduce heartburn in pregnancy.
The nurse is teaching a client with a right-leg fracture who has a prescription for partial weight-bearing status how to ambulate with crutches. The nurse determines that the client demonstrates compliance with this restriction to prevent complications of the fracture if the client follows which direction?
- A. Allows the right foot to only touch the floor
- B. Does not bear any weight on the right leg/foot
- C. Puts 30 \% to 50 \% of the weight on the right leg/foot
- D. Puts 60 \% to 80 \% of the weight on the right leg/foot
Correct Answer: C
Rationale: The client who has partial weight-bearing status is allowed to place 30 \% to 50 \% of the body weight on the affected limb. Touchdown weight-bearing allows the client to let the limb touch the floor but not to bear weight. Nonweight-bearing status does not allow the client to let the limb touch the floor. There is no classification for 60 \% to 80 \% weight-bearing status. Full weightbearing status involves placing full weight on the limb.
The nurse is caring for a client who is a survivor of a disaster event. The client begins to display behaviors not demonstrated before. Which manifestations should indicate to the nurse that the client may be experiencing post-traumatic stress disorder (PTSD)? Select all that apply.
- A. Irritability and sleep disturbances
- B. Flashbacks or recollections of the disaster
- C. Regression to an earlier developmental stage
- D. A feeling of estrangement or detachment from others
- E. Consistent discussion and rationalizing as to why the disaster occurred
- F. Repression or the inability to remember an important aspect associated with the disaster
Correct Answer: A,B,D,F
Rationale: PTSD involves recurrent flashbacks, irritability, sleep disturbances, estrangement, and repression of trauma-related memories. Regression and rationalizing the event's cause are not typical PTSD symptoms. These manifestations indicate a sustained maladaptive response to the traumatic event, often with avoidance of trauma-related stimuli and psychological distress.
The nurse is providing education at a senior center. Which of the following measures will the nurse say is most effective in attaining normal blood pressure in a client with hypertension?
- A. eating red meat daily
- B. increasing potassium and calcium intake
- C. increasing fluid intake
- D. decreasing sodium intake
Correct Answer: D
Rationale: Decreasing sodium intake is the most effective dietary measure to manage hypertension, as sodium increases blood pressure. Red meat (A) may worsen it, potassium/calcium (B) is supportive but less impactful, and fluid intake (C) is not directly related.