Nokea
The nurse has provided home care instructions to a client with prostate cancer who has been hospitalized for a transurethral resection of the prostate (TURP). Which statement by the client indicates the need for further teaching?
- A. Prune juice needs to be included in my diet.
- B. I need to avoid strenuous activity for 4 to 6 weeks.
- C. My intake of water needs to be at least 6 to 8 glasses daily.
- D. I can't lift or push objects that weigh more than 30 pounds.
Correct Answer: D
Rationale: The client needs to be advised to avoid strenuous activity for 4 to 6 weeks and avoid lifting items that weigh more than 20 pounds. Straining during defecation is avoided to prevent bleeding. Prune juice is a satisfactory bowel stimulant. The client needs to consume a daily intake of at least 6 to 8 glasses of nonalcoholic fluids to minimize clot formation.
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During a health assessment the nurse provides instructions to a client regarding the testicular self-examination (TSE). Which statement by the client indicates that the client needs further teaching regarding TSE?
- A. I know to report any small lumps.
- B. I should examine myself every 2 months.
- C. I should examine myself after I take a warm shower.
- D. I know it's normal to feel something that is cord-like in the back.
Correct Answer: B
Rationale: TSE should be performed every month. Small lumps or abnormalities should be reported. The spermatic cord finding is normal. After a warm bath or shower, the scrotum is relaxed, which makes it easier to perform TSE.
Disulfiram has been prescribed for a client, and the nurse provides instructions to the client about the medication. Which statement by the client indicates the need for further teaching?
- A. I must be careful taking cold medicines.
- B. I will have to check my aftershave lotion.
- C. I'll be fine as long as I don't drink alcohol.
- D. I need to be careful with ingredients when I cook.
Correct Answer: C
Rationale: Clients who are taking disulfiram must be taught that substances that contain alcohol can trigger an adverse reaction. Sources of hidden alcohol include foods (soups, sauces, and vinegars), medicine (cold medicine), mouthwashes, and skin preparations (alcohol rubs and aftershave lotions).
The nurse has completed diet teaching for a client on a low-sodium diet for the treatment of hypertension. Which statement by the client should indicate to the nurse that there is a need for further teaching?
- A. Frozen foods are usually lowest in sodium.
- B. This diet will help lower my blood pressure.
- C. This diet is not a replacement for my antihypertensive medications.
- D. The reason I need to lower my salt intake is to reduce fluid retention.
Correct Answer: A
Rationale: A low-sodium diet is used as an adjunct to antihypertensive medications for the treatment of hypertension. Sodium retains fluid, which leads to hypertension as a result of increased fluid volume. Frozen foods use salt as a preservative, which increases their sodium content. Canned foods are extremely high in sodium. Fresh foods are best.
The student nurse is listening to an orthopedic lecture on preoperative education and knee surgeries. Which statement by the student nurse indicates that the teaching has been effective?
- A. Crutch walking instructions should be scheduled before surgery.
- B. Crutch walking instructions should be given on the first postoperative day.
- C. Crutch walking instructions should be scheduled on the second postoperative day.
- D. Crutch walking instructions should be scheduled at the time of discharge after surgery.
Correct Answer: A
Rationale: It is best to assess crutch-walking ability and instruct the client with regard to the use of the crutches before surgery because this task can be difficult to learn when the client is in pain and not used to the imbalance that may occur after surgery. None of the remaining options are appropriate times to teach a client about crutch walking.
The nurse is educating the client on how to save lives and prevent burn injuries, in the event of a fire in the home. Which statement by the client indicates that the teaching has been effective?
- A. I should lace escape ladders in the bedrooms.
- B. I should install a whole-house sprinkler system.
- C. I should keep fresh batteries in smoke detectors.
- D. I should mount fire extinguishers in several areas.
Correct Answer: C
Rationale: The early detection of smoke using a smoke detector and immediate evacuation from the house have significant and positive effects on mortality rates. This is because the smoke alarm activates before the appearance of open flames, which gives people in the house a chance to evacuate without burn injuries. Option 1 helps people in the house escape from second-story rooms safely, but it does not alert the people to the fire before flames are evident, thus exposing them to the risk of burn injury. Installing a sprinkler system is very expensive, and this is usually not done in private residences. Fire extinguishers are a good idea to have in the kitchen and other areas for small fires, but they are not designed to extinguish large fires.