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The nurse is developing a discharge teaching plan for a client who underwent a repair of abdominal aortic aneurysm 4 days ago. The nurse reviews the client's chart for information about the client's history. Key findings are noted in the chart below. Based on the data and expected outcomes, which should the nurse emphasize in the teaching plan?
- A. Food intake
- B. Fluid volume
- C. Skin integrity
- D. Tissue perfusion
Correct Answer: D
Rationale: Post-AAA repair, tissue perfusion is critical to ensure graft patency and prevent ischemia in the lower extremities or organs. Teaching should emphasize signs of poor perfusion (e.g., pain, pallor, pulselessness) and follow-up care. Food, fluid, and skin integrity are less urgent.
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A client who has had a total laryngectomy appears withdrawn and depressed. He keeps the curtain drawn, refuses visitors, and indicates a desire to be left alone. Which nursing intervention would have the threshold to be removed.
- A. Discussing his behavior with his wife to determine the cause.
- B. Exploring his future plans.
- C. Respecting his need for privacy.
- D. Encouraging him to express his feelings nonverbally and in writing.
Correct Answer: D
Rationale: Encouraging nonverbal or written expression allows the client to process emotions despite speech loss, addressing psychological needs. Discussing with his wife breaches confidentiality. Exploring future plans may be premature. Respecting privacy may reinforce withdrawal.
Which of the following is most effective in assessing the client suspected of developing diabetes insipidus?
- A. Taking vital signs every 2 hours.
- B. Measuring urine output hourly.
- C. Assessing arterial blood gas values every other day.
- D. Checking blood glucose levels.
Correct Answer: B
Rationale: Diabetes insipidus, often caused by head injury, leads to excessive dilute urine output. Hourly urine output measurement is the most effective way to detect this condition early. Vital signs, blood gases, and glucose levels are less specific for this diagnosis.
The client with an above-the-knee amputation is to use crutches while his prosthesis is being adjusted. In which of the following exercises should the nurse instruct the client to best prepare him for using crutches?
- A. Abdominal exercises.
- B. Isometric shoulder exercises.
- C. Quadriceps setting exercises.
- D. Triceps stretching exercises.
Correct Answer: B
Rationale: Isometric shoulder exercises strengthen the upper body, essential for crutch walking.
A client with allergic rhinitis asks the nurse what he should do to decrease his symptoms. Which of the following instructions would be appropriate for the nurse to give the client?
- A. Use your nasal decongestant spray regularly to help clear your nasal passages.
- B. Ask the doctor for antibiotics. Antibiotics will help decrease the secretion.
- C. It is important to increase your activity. A daily brisk walk will help promote drainage.
- D. Keep a diary of when your symptoms occur. This is a very small amount of the drug. You identify what precipitates your attacks.
Correct Answer: D
Rationale: Keeping a symptom diary helps identify triggers for allergic rhinitis, enabling avoidance or management strategies. Overuse of decongestant sprays can cause rebound congestion. Antibiotics are ineffective for allergic rhinitis, which is not bacterial. Increased activity like walking does not directly alleviate allergic rhinitis symptoms.
A client experiences initial indications of excitation after having an I.V. infusion of lidocaine hydrochloride started. The nurse should further assess the client when the client reports having:
- A. Palpitations.
- B. Tinnitus.
- C. Urinary frequency.
- D. Lethargy.
Correct Answer: B
Rationale: Tinnitus is a sign of lidocaine toxicity, requiring further assessment to prevent serious complications like seizures or arrhythmias.