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The nurse has taught the client with pleurisy about measures to promote comfort during recuperation. The nurse determines that the client has understood the information if the client states the need to follow which instruction?
- A. Try to take only small, shallow breaths.
- B. Take as much pain medication as possible.
- C. Lie on the affected side as much as possible.
- D. Splint the chest wall during coughing and deep breathing.
Correct Answer: D
Rationale: The client with pleurisy should splint the chest wall during coughing and deep breathing. Taking small, shallow breaths promotes atelectasis. The client should take medication cautiously so that adequate coughing and deep breathing are performed and an adequate level of comfort is maintained. The client may also lie on the affected side to minimize the movement of the affected chest wall.
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The clinic nurse provides home care instructions to a mother regarding the care of her child who is diagnosed with croup. Which statement by the mother indicates the need for further instructions?
- A. I will give Tylenol for the fever.
- B. I will give cough syrup every night at bedtime.
- C. Sips of warm fluids during a croup attack will help.
- D. I will place a cool-mist humidifier next to my child's bed.
Correct Answer: B
Rationale: The mother needs to be instructed that cough syrup and cold medicines should not be administered because they may dry and thicken secretions, worsening croup symptoms. Acetaminophen (Tylenol) is appropriate for reducing fever. Sips of warm fluids help relax the vocal cords and thin mucus. A cool-mist humidifier is recommended to keep the air moist and reduce airway irritation.
A client is being discharged from the hospital after a bronchoscopy that was performed a day earlier. After the discharge teaching, the client makes the following statements to the nurse. Which statement should the nurse identify as indicating a need for further teaching?
- A. I will stop smoking my cigarettes.
- B. I can expect to cough up bright red blood.
- C. I will get help immediately if I start having trouble breathing.
- D. I will use the throat lozenges as directed by my doctor until my sore throat goes away.
Correct Answer: B
Rationale: After bronchoscopy, expectorated secretions are inspected for hemoptysis, and if the client expectorates bright red blood, the primary health care provider is to be notified. The client needs to avoid smoking. The client should be observed for signs/symptoms of respiratory distress, including dyspnea, changes in respiratory rate, the use of accessory muscles, and changes in or absent lung sounds. A sore throat is common, and lozenges would be helpful to alleviate it.
To promote self-care, the nurse is planning to teach a client in skeletal leg traction about measures to increase bed mobility. Which item is most helpful for this client for achievement of this goal?
- A. Fracture bedpan
- B. Overhead trapeze
- C. Isometric exercises
- D. Range-of-motion exercises
Correct Answer: B
Rationale: The use of an overhead trapeze is extremely helpful for assisting a client with moving about in bed and getting on and off the bedpan. This device has the greatest value for increasing overall bed mobility. A fracture bedpan is useful for reducing discomfort with elimination. Isometric exercises will not increase bed mobility and could be harmful for a client in skeletal traction. Range-of-motion exercises can also be harmful to a client in skeletal traction and should not be initiated unless there are specific prescriptions to do so.
The nurse provides home care instructions to a client diagnosed with Cushing's syndrome. The nurse determines that the client understands the hospital discharge instructions if the client makes which statement?
- A. I need to eat foods low in potassium.
- B. I need to check the color of my stools.
- C. I need to check the temperature of my legs twice a day.
- D. I need to take aspirin rather than acetaminophen for a headache.
Correct Answer: B
Rationale: Cushing's syndrome results in an increased secretion of cortisol. Cortisol stimulates the secretion of gastric acid, and this can result in the development of peptic ulcers and gastrointestinal bleeding. The client should be encouraged to eat potassium-rich foods to correct the hypokalemia that occurs with this disorder. Cushing's syndrome does not affect temperature changes in the lower extremities. Aspirin can increase the risk for gastric bleeding and skin bruising.
The nurse teaches a client at risk for coronary artery disease about lifestyle changes needed to reduce his risks. The nurse determines that the client understands these necessary lifestyle changes if the client makes which statements?
- A. I will attempt to stop smoking.
- B. I will be sure to include some exercise such as walking in my daily activities.
- C. I will work at losing some weight so that my weight is at normal range for my age.
- D. I will limit my sodium intake every day and avoid eating high-sodium foods such as hot dogs.
- E. It is acceptable to eat red meat and cheese every day as I have been doing, as long as I cut down on the butter.
- F. I will schedule regular doctor appointments for physical examinations and monitoring my blood pressure.
Correct Answer: B,C,D,F
Rationale: Coronary artery disease affects the arteries that provide blood, oxygen, and nutrients to the myocardium. Modifiable risk factors include elevated serum cholesterol levels, cigarette smoking, hypertension, impaired glucose tolerance, obesity, physical inactivity, and stress. The client is instructed to stop smoking (not cut down), and the nurse should provide the client with resources to do so. The client is also instructed to maintain a normal weight and include physical activity in the daily schedule. The client needs to limit sodium intake and foods high in cholesterol, including red meat and cheese. The client must follow up with regular primary health care provider appointments for physical examinations and monitoring blood pressure.