Nokea
The nurse has reinforced teaching for a client with newly diagnosed von Willebrand disease. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. I can use a humidifier to help prevent nosebleeds.
- B. I need to wear gloves while doing yard work.
- C. I should use a soft-bristled toothbrush and floss carefully.
- D. I will notify my health care provider if I soak a menstrual pad in an hour.
- E. I will take NAPROXEN to decrease pain and inflammation if I am injured.
Correct Answer: A,C,D
Rationale: Using a humidifier (A) prevents mucosal drying and nosebleeds. A soft-bristled toothbrush and careful flossing (C) minimize gum bleeding. Reporting heavy menstrual bleeding (D) is critical to manage bleeding risks in von Willebrand disease.
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Which instructions should the nurse include when reinforcing discharge teaching to a client with peptic ulcer disease due to Helicobacter pylori infection? Select all that apply.
- A. Avoid foods that may cause epigastric distress such as spicy or acidic foods.
- B. It is best if you refrain from consuming alcohol products.
- C. Report black tarry stools to your health care provider immediately
- D. Take your amoxicillin, clarithromycin, and omeprazole for the next 14 days.
- E. You may take over-the-counter drugs such as aspirin if you have mild epigastric pain.
Correct Answer: A,B,C,D
Rationale: Avoiding irritants (A), abstaining from alcohol (B), reporting melena (C), and completing the antibiotic regimen (D) are critical for managing H. pylori-related peptic ulcer disease.
The nurse is reviewing teaching about newly prescribed clonazepam with a client who is receiving palliative care for cancer. Which client statement shows a correct understanding of the nurse's teaching?
- A. I am glad that I can continue to take my kava supplement each morning.
- B. If I can't sleep, I will take some melatonin with my evening dose of clonazepam.
- C. If I feel restless, I can put some drops of lavender essential oil in a diffuser to calm myself.
- D. When my anxiety is getting really intense, I will drink some valerian tea to help me relax.
Correct Answer: C
Rationale: Lavender essential oil in a diffuser is a safe, non-pharmacological method to reduce restlessness, compatible with clonazepam without risk of interaction.
Which one of these tasks can be safely delegated to a practical nurse (PN)?
- A. Assess the function of a newly created ileostomy
- B. Care for a client with a recent complicated double barrel colostomy
- C. Provide stoma care for a client with a well functioning ostomy
- D. Teach ostomy care to a client and their family members
Correct Answer: C
Rationale: Provide stoma care for a client with a well functioning ostomy. The care of a mature stoma and the application of an ostomy appliance may be delegated to a PN. This client has minimal risk of instability of the situation.
The nurse is contributing to the plan of care for an 8-year-old client with autism spectrum disorder. Which of the following interventions should the nurse suggest including in the client's plan of care? Select all that apply.
- A. Establish a consistent schedule for providing care.
- B. Encourage the parents to be present when providing care.
- C. Assign the same staff members to care for the client when possible.
- D. Place the client in a private room with familiar belongings.
- E. Use therapeutic touch to comfort the client.
Correct Answer: A,B,C,D
Rationale: Consistency in schedule (A), parental presence (B), familiar staff (C), and a private room with familiar items (D) reduce anxiety in children with autism. Therapeutic touch (E) may be distressing due to sensory sensitivities.
Which of these tests would the nurse expect to monitor for the evaluation of clients aged 18 and older with poor glycemic control?
- A. A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up assessment, which should occur in longer than 3-month intervals
- B. A glycosylated hemoglobin is to be obtained at least two years
- C. A fasting glucose and a glycosylated hemoglobin is to be obtained at 3 months intervals after the initial assessment
- D. A glucose tolerance test, a fasting glucose and a glycosylated hemoglobin should be obtained at 6-month intervals after the initial assessment
Correct Answer: A
Rationale: The American Diabetes Association (ADA) recommends obtaining a glycosylated hemoglobin during an initial assessment and then routinely as part of continuing care for clients with poor glycemic control.