Nokea
The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
- A. exercise doing weight bearing activities
- B. exercise to reduce weight
- C. avoid exercise activities that increase the risk of fracture
- D. exercise to strengthen muscles and thereby protect bones
Correct Answer: A
Rationale: exercise doing weight bearing activities. Weight bearing exercises are beneficial in the treatment of osteoporosis. Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the client includes weight bearing exercises along with estrogen replacement and calcium supplements in their treatment protocol.
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Which information is most important for the nurse to reinforce with a male client who is about to undergo a vasectomy?
- A. Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.'
- B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate.'
- C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you may return to work as soon as you feel up to it.'
- D. The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.'
Correct Answer: A
Rationale: All of these options are correct information. The most important point to reinforce is the continuing need to take additional action for birth control until the absence of sperm in the ejaculate is confirmed.
The nurse completed discharge teaching for the client with sutures in place after a skin biopsy. Which statements by the client indicate an understanding of the teaching? Select all that apply.
- A. "The incision should be clean, dry, and not separated."
- B. "I will return in 2 to 3 days to have the stitches removed."
- C. "If I have an elevated temperature, I'll contact my provider."
- D. "I'll keep the bandage on for a week before I check the incision."
- E. "Excessive redness, pain, or drainage may mean it is infected."
Correct Answer: A,C,E
Rationale: A: Clean, dry, intact incisions indicate proper care. C: Fever suggests infection, requiring follow-up. E: Redness, pain, or drainage are infection signs. B: Sutures are removed in 7-10 days. D: Incisions should be checked daily.
After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate to suggest?
- A. 3 oz broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk
- B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
- C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
- D. 3 oz turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
Correct Answer: D
Rationale: 3 oz turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange. Canned fish and vegetables and cured meats are high in sodium. This meal does not contain any canned fish and/or vegetables or cured meats.
The hospitalized client has protective precautions (reverse isolation) in place because of severe neutropenia. Which statement by the nurse to the NA is correct regarding the use of protective precautions?
- A. "You should don gloves as soon as you enter the client's room."
- B. "Minimize the amount of time the client spends outside the room."
- C. "The client needs to be moved to a private room with negative air pressure."
- D. "Everyone entering the client's room should be sure to put on a mask."
Correct Answer: B
Rationale: B: Minimizing time outside the room reduces pathogen exposure. A, D: Gloves and masks are not required unless infection is present. C: Positive, not negative, air pressure is needed.
The nurse is assessing an 8 month-old child with atonic cerebral palsy. Which statement from the parent supports the presence of this problem?
- A. When I put my finger in the left hand the baby doesn't respond with a grasp.'
- B. My baby doesn't seem to follow when I shake toys in front of its face.'
- C. When it thundered loudly last night the baby didn't even jump.'
- D. When I put the baby in a back lying position that's how I find it hours later.'
Correct Answer: D
Rationale: When I put the baby in a back lying position that's how I find it hours later.' Atonic cerebral palsy is characterized by low muscle tone and lack of movement, so the baby remaining in the same position for hours supports this diagnosis.