Nokea
The nurse is caring for a client with cirrhosis who has ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which of the following actions should the nurse take? Select all that apply.
- A. Assist the client to ambulate in the hallway every shift
- B. Encourage the client to increase sodium intake
- C. Maintain the client in semi-Fowler position
- D. Provide an alternating air pressure mattress for the client
- E. Use music to provide a distraction for the client
Correct Answer: C,D,E
Rationale: Semi-Fowler position helps alleviate shortness of breath by reducing pressure on the diaphragm. An alternating air pressure mattress reduces the risk of pressure injuries due to immobility. Music can help reduce discomfort and anxiety, providing a non-pharmacological distraction.
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The best method of evaluating the amount of peripheral edema is:
- A. Weighing the client daily
- B. Measuring the extremity
- C. Measuring the intake and output
- D. Checking for pitting
Correct Answer: B
Rationale: Measuring the extremity provides a direct and quantifiable assessment of peripheral edema by tracking changes in circumference. Daily weighing can indicate fluid retention but is less specific, so answer A is incorrect. Intake and output monitoring does not directly measure edema, so answer C is incorrect. Checking for pitting assesses the presence of edema but not its amount, so answer D is incorrect.
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.
The nurse is caring for an older client who had a cerebrovascular accident (CVA) several days ago. She is having trouble speaking. How should the nurse relate to this client?
- A. Encourage the client to speak and wait patiently while she tries
- B. Speak louder to the client
- C. Finish the client's sentences when she is having difficulty
- D. Tell the client to rest her voice for the next few days
Correct Answer: A
Rationale: Encouraging speech with patience supports recovery in aphasia post-CVA, unlike loud speech, finishing sentences, or voice rest, which hinder communication progress.
A client hospitalized with mania is racing wildly about the unit trying to organize the other clients into a game of Ping-Pong. The nurse should:
- A. Send the client to the recreation room for art therapy.
- B. Take the client outside for a walk.
- C. Allow the client to continue because his activities are goal directed.
- D. Suggest that the client do exercises to a video instead.
Correct Answer: B
Rationale: Taking the client for a walk redirects energy safely and reduces stimulation. Art therapy may not engage, continuing the activity risks escalation, and video exercises lack supervision.
The nurse reinforces teaching to a client prescribed isoniazid, rifampin, ethambutol, and pyrazinamide to treat active tuberculosis. Which of the following instructions associated with the adverse effects of rifampin is most important for the nurse to include?
- A. Notify the health care provider if your urine is red
- B. Take acetaminophen every 6 hours for drug-associated joint pain while taking this medication
- C. Wear eyeglasses instead of soft contact lenses while taking this medication
- D. You can stop taking the medications as soon as one sputum culture comes back normal
Correct Answer: C
Rationale: Rifampin can stain soft contact lenses orange-red, so wearing eyeglasses prevents this issue, making it a key instruction for adherence.