Nokea
The nurse has provided home-care instructions to a client who is taking lithium carbonate. Which client statement indicates that the client understands the prescribed regimen?
- A. I will restrict my water intake.
- B. I will make sure that my diet contains salt.
- C. I will keep my medication in the refrigerator.
- D. I will be careful to avoid eating foods high in potassium.
Correct Answer: B
Rationale: Lithium is a mood stabilizer used to treat bipolar disorder. It replaces sodium ions in the cells and induces the excretion of sodium and potassium from the body. Client teaching includes the maintenance of sodium intake in the daily diet and increased fluid intake (at least 1 to 1½ L per day) during maintenance therapy. Lithium is stored at room temperature and protected from light and moisture.
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The nurse is teaching a new mother about postpartum fatigue (PPF). Which information would the nurse include?
- A. PPF is more common in women with cesarean births.
- B. Fatigue usually improves over the first 6 weeks after birth.
- C. Fatigue can help reduce the incidence of postpartum depression.
- D. Nursing mothers can minimize fatigue by breastfeeding in the side-lying position.
Correct Answer: B,D
Rationale: Fatigue improves over 6 weeks, and side-lying breastfeeding conserves energy. Cesarean births don't inherently increase PPF, and fatigue may worsen depression.
A pediatric nurse in an ambulatory care clinic is admitting a neonate for the 2-week office visit. Which comment by the mother should alert the nurse to suspect colic?
- A. My baby looks yellow.
- B. After feedings, my baby pulls his legs up and cries.
- C. My baby is quiet and doesn't cry much.
- D. My baby is alert for brief periods of 10-20 minutes at a time.
Correct Answer: B
Rationale: Pulling legs up and crying after feedings suggests colic. Jaundice, quietness, or brief alertness are not indicative of colic.
The nurse prepares a client with a peripheral intravenous (IV) site for home IV therapy for discharge. Which should the nurse teach the client to help prevent phlebitis and infiltration?
- A. Massage the IV site daily.
- B. Immobilize the extremity.
- C. Stabilize the cannula with tape.
- D. Cleanse the site daily with alcohol.
Correct Answer: C
Rationale: Stabilizing the cannula with tape prevents movement, reducing the risk of phlebitis and infiltration. Massaging the site can cause tissue damage, immobilizing the extremity is unnecessary, and alcohol cleansing causes skin drying and discomfort.
The nurse is educating a client who is 10 weeks pregnant about prenatal nutrition. The client is of normal weight. Which statement by the client indicates an understanding of weight gain during pregnancy?
- A. I should gain 15 to 20 pounds.
- B. I should gain 25 to 35 pounds.
- C. I should gain 35 to 40 pounds.
- D. I should gain 40 to 45 pounds.
Correct Answer: B
Rationale: Normal-weight women should gain 25-35 pounds during pregnancy, as per guidelines.
The nurse has completed discharge teaching with a client who has had surgery for lung cancer. The nurse determines that the client needs additional teaching about the elements of home management if the client verbalizes the need to follow which instruction?
- A. Avoid exposure to crowds.
- B. Deal with any increases in pain independently.
- C. Sit up and lean forward to breathe more easily.
- D. Call the primary health care provider if shortness of breath occurs.
Correct Answer: B
Rationale: Clients post-lung cancer surgery should not manage increased pain independently, as it may indicate complications requiring medical attention. Avoiding crowds, sitting up to breathe easier, and reporting shortness of breath are appropriate home management strategies.