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The nurse in a long-term care facility is talking with a client with multiple sclerosis who states, 'I want to live in my own home again.' Which of the following responses would be most appropriate for the nurse to make?
- A. Do you have family or friends who could live with you?
- B. I will refer you to a local home-health agency.
- C. How will you manage your care at home?
- D. Tell me more about your concerns.
Correct Answer: D
Rationale: Encouraging the client to express their concerns promotes client-centered care and helps the nurse understand the client's motivations and needs for returning home.
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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 caring for a hospitalized adult who is receiving a blood transfusion. Twenty minutes after the start of the transfusion, the client complains of feeling cold and is shivering. What is the best first action for the LPN to take?
- A. Put a warm blanket on the client
- B. Take the client's vital signs
- C. Elevate the client's feet
- D. Stop the transfusion
Correct Answer: D
Rationale: Shivering and feeling cold during a transfusion suggest a possible transfusion reaction, requiring immediate cessation of the transfusion to prevent further complications, followed by vital signs and physician notification.
A 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child's greatest fear?
- A. Change in body image
- B. An unfamiliar environment
- C. Perceived loss of control
- D. Guilt over being hospitalized
Correct Answer: C
Rationale: For school-age children, major fears are loss of control and separation from friends/peers.
The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report
- A. Loss of consciousness
- B. Feeding problems
- C. Poor weight gain
- D. Fatigue with crying
Correct Answer: A
Rationale: Loss of consciousness. This indicates anoxia, which may lead to death, requiring immediate reporting.
A client with severe hypertension is receiving Capoten (captopril). The nurse should instruct the client to report which of the following to the doctor?
- A. Coughing
- B. Drowsiness
- C. Frequent urination
- D. Hunger
Correct Answer: A
Rationale: A persistent cough is a common side effect of ACE inhibitors like captopril, potentially requiring a change in medication.