Nokea
The nurse is preparing a client diagnosed with pneumonia for discharge. Which statement by the client should alert the nurse to the fact that the client needs further teaching before being discharged?
- A. I will take all of my antibiotics, even if I do feel 100% better.
- B. You can toss out that incentive spirometer as soon as I leave for home.
- C. I realize that it may be weeks before my usual sense of well-being returns.
- D. It is a good idea for me to take a nap every afternoon for the next couple of weeks.
Correct Answer: B
Rationale: Deep breathing and coughing exercises and the use of incentive spirometry should be practiced for 6 to 8 weeks after the client diagnosed with pneumonia is discharged from the hospital to keep the alveoli expanded and promote the removal of lung secretions. If the entire regimen of antibiotics is not taken, the client may suffer a relapse. The period of convalescence with pneumonia is often lengthy, and it may be weeks before the client feels a sense of well-being. Adequate rest is needed to maintain progress toward recovery.
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The clinic nurse is talking to a client who has just been prescribed hormone replacement therapy (HRT). Which statement about HRT by the nurse is correct?
- A. HRT decreases the risk of stroke.
- B. HRT increases the risk of osteoporosis.
- C. HRT decreases the risk of deep vein thrombosis.
- D. HRT increases the risk of coronary artery disease.
Correct Answer: D
Rationale: HRT increases the risk of coronary artery disease. It does not decrease stroke or DVT risk and helps prevent osteoporosis.
The nurse creates a plan of care for an older client diagnosed with diabetes mellitus. It is important that the nurse plans to complete which action first?
- A. Structure menus for adherence to diet.
- B. Teach with videotapes showing insulin administration to ensure competence.
- C. Encourage dependence on others to prepare the client for the chronicity of the disease.
- D. Assess the client's ability to read label markings on syringes and blood glucose monitoring equipment.
Correct Answer: D
Rationale: Assessing the client's ability to read syringe and glucose monitor markings is the first step, ensuring they can manage self-care. Structuring menus or teaching with videos assumes capability, and encouraging dependence is inappropriate.
A client with a colostomy complains to the nurse of appliance odor. The nurse recommends that the client take in which deodorizing foods?
- A. Eggs
- B. Yogurt
- C. Cucumbers
- D. Mushrooms
Correct Answer: B
Rationale: Foods that help eliminate odor with a colostomy include yogurt, buttermilk, cranberry juice, and parsley. Foods that cause odor are many and include alcohol, beans, turnips, radishes, asparagus, onions, cucumbers, mushrooms, cabbage, eggs, and fish.
The nurse is performing an assessment on an older client. Which signs/symptoms are age-related changes in the eye? Select all that apply.
- A. Clear sclera
- B. Blurred vision
- C. Protruding cornea
- D. Increased tear production
- E. Diminished pupillary adaptation to darkness
- F. Increased ability to discriminate among colors
Correct Answer: B,E
Rationale: Age-related changes in the eye include flattening of the cornea, which causes blurred vision; poor pupillary adaptation to darkness; yellowing sclera; a sunken appearance; diminished tear production; diminished ability to discriminate among colors; and reduced ocular muscle strength.
The nurse is teaching a mother diagnosed with diabetes mellitus who delivered a large-for-gestational-age (LGA) infant about the care of the infant. The nurse tells the mother that LGA infants appear to be more mature because of their large size, but that, in reality, these infants frequently need to be aroused to facilitate nutritional intake and attachment. Which statement by the mother indicates the need for additional teaching about the care of the infant?
- A. I will talk to my baby when he is in a quiet, alert state.
- B. I will allow my baby to sleep through the night because he needs his rest.
- C. I will breast-feed my baby every 2½ to 3 hours and will use arousal techniques.
- D. I will watch my baby closely because I know that he may not be as mature in his motor development.
Correct Answer: B
Rationale: LGA infants tend to be more difficult to arouse and therefore must be aroused to facilitate nutritional intake and attachment opportunities. These infants also have problems maintaining a quiet, alert state. It is beneficial for the mother to interact with the infant during this time to enhance and lengthen the quiet, alert state. LGA infants need to be aroused for feedings, usually every 2½ to 3 hours for breast-feeding. Although the infant is large, motor function is not usually as mature as it is in the term infant.