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The nurse has provided instructions to a client who is receiving external radiation therapy. Which statement by the client indicates a need for further teaching regarding self-care related to the radiation therapy?
- A. I need to eat a high-protein diet.
- B. I need to avoid exposure to sunlight.
- C. I need to wash my skin with a mild soap and pat it dry.
- D. I need to apply pressure on the irritated area to prevent bleeding.
Correct Answer: D
Rationale: The client receiving external radiation therapy should avoid pressure on the irritated area and wear loose-fitting clothing. Specific health care provider instructions would be necessary to obtain if an alteration in skin integrity occurred as a result of the radiation therapy. The remaining options are accurate measures regarding radiation therapy.
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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.
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.
A home care nurse is instructing a mother of a child diagnosed with cystic fibrosis (CF) about the appropriate dietary measures. Which diet should the nurse tell the mother that the child needs to consume?
- A. Low-calorie, low-fat diet
- B. High-calorie, restricted fat
- C. Low-calorie, low-protein diet
- D. High-calorie, high-protein diet
Correct Answer: D
Rationale: Children with CF are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy and fat-soluble vitamin supplements are administered. Fat restriction is not necessary.
The nurse is providing discharge teaching for a client diagnosed and treated for tuberculosis (TB). Which statement by the client indicates that teaching has been effective? Select all that apply.
- A. All used dishes should be sterilized.
- B. My close contacts should be tested for TB.
- C. Soiled tissues should be disposed of properly.
- D. House isolation is required for at least 8 months.
- E. The mouth should always be covered when coughing.
Correct Answer: B,C,E
Rationale: Tuberculosis is a communicable disease, and the nurse must teach the client measures to prevent its spread. Any close contacts with the client must be tested and treated if the results of the screening test are positive. Because it is an airborne disease, the client must properly dispose of used tissues and needs to cover the mouth when coughing. There is no evidence to suggest that sterilizing dishes would break the chain of infection with pulmonary TB. It is not necessary for the client to isolate herself or himself to the house. Once the client is treated and results of three sputum cultures are negative, the client will not spread the infection.
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.