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The nurse is observing a client who is recovering from back strain lift a box as shown below. What should the nurse do?
- A. Praise the client for using correct body mechanics.
- B. Suggest to the client that she put both knees on the floor before attempting to lift the box.
- C. Advise the client to bend from the waist rather than stretching her back in this position.
- D. Inform the client that she should keep her back straight by squatting with both knees parallel.
Correct Answer: A
Rationale: The client is using correct body mechanics for lifting because she is keeping her back as straight as possible and is holding the box close to her body. She is using her large leg muscles to lift the box. She is using a broad base of support by placing her feet as wide apart as possible. The other suggestions would cause the client to put a strain on her back.
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After stabilization of Addison's disease, the nurse teaches the client about stress management. The nurse should instruct the client to:
- A. Remove all sources of stress from daily life.
- B. Use relaxation techniques such as music.
- C. Take antianxiety drugs daily.
- D. Avoid discussing stressful experiences.
Correct Answer: B
Rationale: Relaxation techniques like music help manage stress, reducing glucocorticoid demands in Addison's disease.
After surgery for head and neck cancer, a client has a permanent tracheostomy. The nurse should teach the client and family about the importance of:
- A. Providing tracheostomy site care.
- B. Addressing the psychosocial issues related to tracheostomy.
- C. Observing for early signs and symptoms of skin breakdown around the tracheostomy site.
- D. Using humidifiers to prevent thick, tenacious secretions.
Correct Answer: A,C,D
Rationale: Tracheostomy site care (A), monitoring for skin breakdown (C), and using humidifiers (D) are critical to prevent infection, maintain skin integrity, and keep secretions manageable.
A client with advanced ovarian cancer takes 150 mg of long-acting morphine orally every 12 hours for abdominal pain. When the client develops a small bowel obstruction, the physician discontinues the oral morphine and begins morphine 6 mg/hour I.V. After calculating the equianalgesic conversion from oral to intravenous morphine, the nurse should:
- A. Continue the oral morphine for one more dose after the I.V. morphine is started.
- B. Contact the physician to suggest a higher equianalgesic dose of I.V. morphine.
- C. Administer the morphine I.V. as ordered.
- D. Clarify the order to recommend the initial morphine dose of 4 mg/hour.
Correct Answer: B
Rationale: The equianalgesic conversion from 150 mg oral morphine every 12 hours (300 mg/day oral) to I.V. morphine (1:3 ratio) is approximately 100 mg/day I.V., or 4.2 mg/hour. The ordered 6 mg/hour is too high, and the nurse should contact the physician to adjust the dose.
The client states she does not understand what causes idiopathic thrombocytopenic purpura (ITP). The nurse provides which of the following explanations?
- A. It is believed that the platelets are coated with antibodies and the spleen sees them as foreign bodies.
- B. It is believed that the liver identifies the platelets as foreign bodies.
- C. It is now believed that the syndrome is related to an underactive immune system.
- D. The cause is unknown.
Correct Answer: A
Rationale: Idiopathic thrombocytopenic purpura (ITP) is an autoimmune condition where antibodies coat platelets, marking them for destruction by the spleen. This leads to a low platelet count. The liver is not primarily involved, ITP is not due to an underactive immune system, and while 'idiopathic' means the exact trigger is unknown, the autoimmune mechanism is well-established.
A 65-year-old male has hearing loss and a sensation of fullness in both ears. The nurse examines his ears with the understanding of the cause of hearing loss in older adults is related to:
- A. Accumulation of cerumen in the external canal.
- B. Accumulation of cerumen in the internal canal.
- C. External otitis.
- D. Exostosis.
Correct Answer: A
Rationale: Accumulation of cerumen in the external canal is a common cause of conductive hearing loss in older adults, leading to a sensation of fullness and reduced hearing.