Nokea
The nurse has taught a client with a below-the-knee amputation about home care and about monitoring for and preventing complications related to prosthesis and residual limb care. The nurse determines that the client has understood the instructions if the client stated that which action should be taken?
- A. Wear a clean nylon sock over the residual limb every day.
- B. Use a mirror to inspect all areas of the residual limb each day.
- C. Toughen the skin of the residual limb by rubbing it with alcohol.
- D. Prevent cracking of the skin of the residual limb by applying lotion daily.
Correct Answer: B
Rationale: The client should inspect all surfaces of the residual limb daily for irritation, blisters, and breakdown. The client should wear a clean woolen (not nylon) sock each day. The residual limb is cleansed daily with a gentle soap and water and dried carefully. Alcohol is avoided because it could cause drying or cracking of the skin. Oils and creams are also avoided because they are too softening to the skin for safe prosthesis use.
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A client is receiving education on cholesterol. Which of the following statements from the client indicates the need for further teaching?
- A. I would like my HDL levels to be over 50.
- B. It is better for me to have high HDL levels and low LDL levels.
- C. It is better for me to have high LDL levels and low HDL levels.
- D. My goal is to get my total cholesterol below 200.
Correct Answer: C
Rationale: The correct answer is, 'It is better for me to have high LDL levels and low HDL levels.' This statement indicates a need for further teaching because high LDL levels contribute to atherosclerosis, while high HDL levels can protect against heart disease. The client should understand the importance of lowering LDL levels and increasing HDL levels to maintain good heart health. Choice A is correct as desiring HDL levels over 50 is a positive goal. Choice B is correct as it reflects the ideal scenario of high HDL and low LDL levels. Choice D is correct as a total cholesterol below 200 is a common goal for heart health. Therefore, Choice C is incorrect as it suggests an opposite and unhealthy relationship between LDL and HDL levels.
Clonazepam has been prescribed for the client, and the nurse teaches the client about the medication. Which statement by the client indicates that further teaching is necessary?
- A. If I experience slurred speech, it will disappear in about 8 weeks.
- B. My drowsiness will decrease over time with continued treatment.
- C. I should take my medicine with food to decrease stomach problems.
- D. I can take my medicine at bedtime if it tends to make me feel drowsy.
Correct Answer: A
Rationale: Clonazepam is a benzodiazepine. Clients who experience signs/symptoms of toxicity with the administration of clonazepam exhibit slurred speech, sedation, confusion, respiratory depression, hypotension, and eventually coma. Some drowsiness may occur, but it will decrease with continued use. The medication may be taken with food to decrease gastrointestinal irritation. The medication may be taken at bedtime if drowsiness does occur. Slurred speech indicates toxicity and should be reported immediately, not expected to disappear in 8 weeks.
Which of the following is a true statement about assessing blood pressure by palpation?
- A. Only the diastolic blood pressure can be assessed through palpation.
- B. The palpation technique is most useful for infants and small children.
- C. Hypertension is a common condition that might need to be assessed through blood pressure palpation.
- D. Only the systolic blood pressure can be assessed through palpation.
Correct Answer: D
Rationale: When assessing blood pressure by palpation, it is important to note that only the systolic blood pressure can be determined accurately using this method. Diastolic blood pressure cannot be reliably assessed through palpation. The palpation technique is particularly useful in situations where traditional blood pressure measurement methods are challenging, such as in infants, small children, or individuals with low blood pressure that is difficult to hear. Hypertension, a common condition characterized by elevated blood pressure, is typically assessed using auscultation rather than palpation. Therefore, the correct statement is that only the systolic blood pressure can be assessed through palpation.
A client with a broken femur is in a traction splint in bed. Which of the following interventions is NOT part of caring for this client?
- A. Palpating the temperature of both feet
- B. Evaluating pulses bilaterally
- C. Turning the client to a side-lying position
- D. Relieving heel pressure by placing a pillow under the foot
Correct Answer: C
Rationale: When caring for a client with a broken femur in a traction splint, turning the client to a side-lying position is not recommended. This client is at risk of skin breakdown and complications due to the injury, making it important to prevent unnecessary movement that may increase the risk of injury or discomfort. Palpating the temperature of both feet helps in assessing circulation, evaluating pulses bilaterally ensures perfusion to the extremities, and relieving heel pressure by placing a pillow under the foot helps in reducing pressure points and preventing complications like pressure ulcers. Therefore, the correct answer is turning the client to a side-lying position as it is not a recommended intervention in this scenario.
The nurse should tell the client to avoid which item while taking phenelzine sulfate?
- A. Blueberries
- B. Vasodilators
- C. Aged cheeses
- D. Digitalis preparations
Correct Answer: C
Rationale: Phenelzine sulfate is in the monoamine oxidase inhibitor (MAOI) class of antidepressant medications. An individual taking an MAOI must avoid aged cheeses, alcoholic beverages, avocados, bananas, and caffeine drinks. There are also other food items to avoid, including chocolate, meat tenderizers, pickled herring, raisins, sour cream, yogurt, and soy sauce. Medications that should be avoided include amphetamines, antiasthmatics, and certain antidepressants. The client should also avoid vasoconstrictors because their concurrent use can cause hypertensive crisis.