Nokea
The nurse is creating a teaching plan for the client with Raynaud's disease. Which instruction should the nurse include?
- A. Daily cool baths will provide an analgesic effect.
- B. A high-protein diet will minimize tissue malnutrition.
- C. Vitamin K administration will prevent tendencies toward bleeding.
- D. Keeping the hands and feet warm and dry will prevent vasoconstriction.
Correct Answer: D
Rationale: Raynaud's disease is a vasospasm of the arterioles and arteries of the upper and lower extremities. The use of measures to prevent vasoconstriction is helpful for the management of Raynaud's disease. The hands and feet should be kept dry. Gloves and warm fabrics should be worn in cold weather, and the client should avoid exposure to nicotine and caffeine. The avoidance of situations that trigger stress is also helpful. Taking daily cool baths, maintaining a high-protein diet, and administering vitamin K are not components of the treatment for this disorder.
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The nurse teaches a client with hypertension to recognize the signs/symptoms that may occur during periods of elevated blood pressure. The nurse determines that the client needs additional teaching if the client states that which sign/symptom is associated with this condition?
- A. Epistaxis
- B. Dizziness
- C. Blurred vision
- D. A feeling of fullness in the head
Correct Answer: D
Rationale: A feeling of fullness in the head is more likely associated with a sinus condition than hypertension. Cerebrovascular symptoms of hypertension include early morning headaches, occipital headaches, epistaxis, dizziness, blurred vision, lightheadedness, and vertigo. The client should be aware of these signs/symptoms and report them if they occur. The client should also be taught to self-monitor the blood pressure.
The nurse is providing discharge instructions to the mother of an 8-year-old child who had a tonsillectomy. The mother tells the nurse that the child loves tacos and asks when the child can safely eat one. To prevent complications of the surgical procedure, what should be the appropriate response to the mother?
- A. In 1 week.
- B. In 3 weeks.
- C. Six days after surgery.
- D. When the primary health care provider says it is okay.
Correct Answer: B
Rationale: Rough or scratchy foods, as well as spicy foods, are to be avoided for 3 weeks after a tonsillectomy. Citrus juices that irritate the throat should be avoided for 10 days. Red liquids are avoided because they will give the appearance of blood if the child vomits. The mother is instructed to add full liquids on the second day and soft foods as the child tolerates them.
The nurse is providing home care dietary instructions to a client who has been hospitalized for pancreatitis. Which food should the nurse instruct the client to avoid to prevent recurrence?
- A. Chili
- B. Bagels
- C. Lentil soup
- D. Watermelon
Correct Answer: A
Rationale: Pancreatitis involves inflammation of the pancreas, and spicy foods like chili can stimulate pancreatic secretions, potentially triggering a recurrence. The client should eat small, frequent meals that are high in protein, low in fat, and moderate to high in carbohydrates. Bagels, lentil soup, and watermelon are generally bland and acceptable.
The community health nurse teaches a group of females how to prevent pelvic inflammatory disease (PID). What instruction should the nurse include?
- A. To douche monthly
- B. To avoid unprotected intercourse
- C. To use only ultra-low dose oral contraceptive pills
- D. To consult with a gynecologist regarding the placement of an intrauterine device (IUD)
Correct Answer: B
Rationale: PID is an infection of the pelvis. The primary prevention of PID includes avoiding unprotected intercourse. Douching leads to a higher risk for PID. It is believed that high hormonal doses may decrease risk of PID, but ultra-low doses will not. The use of an IUD may also increase the risk for PID.
The nurse has completed instructions with a client with atrial fibrillation who will be taking warfarin sodium indefinitely. Which statement by the client indicates the need for further teaching?
- A. I need to use a soft toothbrush.
- B. I need to avoid drinking alcohol while taking this medication.
- C. I can continue to take my NSAIDs as previously prescribed.
- D. I should carry identification regarding the medication being taken.
Correct Answer: C
Rationale: Warfarin increases bleeding risk, and NSAIDs can exacerbate this, especially causing GI bleeding, so they should be avoided without provider approval. Using a soft toothbrush, avoiding alcohol, and carrying medication identification are correct to prevent bleeding and ensure safety.