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The nurse is providing discharge teaching to a client with gastroesophageal reflux disease (GERD). Which instruction should the nurse include in the teaching?
- A. Increase fluid intake with meals
- B. Avoid lying down for at least 30 minutes after eating
- C. Eat small, frequent meals throughout the day
- D. Consume spicy foods in moderation
Correct Answer: C
Rationale: The correct instruction for the nurse to include in the teaching for a client with GERD is to eat small, frequent meals throughout the day. This recommendation helps reduce symptoms by preventing the stomach from becoming overly full, which can increase pressure on the lower esophageal sphincter and lead to acid reflux. Choices A, B, and D are incorrect because increasing fluid intake with meals can exacerbate GERD symptoms, lying down after eating can worsen reflux, and consuming spicy foods can trigger acid reflux in individuals with GERD.
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A client with deep vein thrombosis (DVT) is prescribed heparin therapy. What laboratory value should the nurse monitor?
- A. Monitor the client's liver function tests.
- B. Monitor the client's prothrombin time (PT).
- C. Monitor the client's partial thromboplastin time (PTT).
- D. Monitor the client's red blood cell count.
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's partial thromboplastin time (PTT). During heparin therapy for DVT, it is essential to monitor the PTT to assess the effectiveness of the medication in preventing clot formation. Monitoring the PTT helps ensure that the client is within the therapeutic range for anticoagulation. Choices A, B, and D are incorrect because liver function tests, prothrombin time (PT), and red blood cell count are not specifically monitored to assess the effectiveness of heparin therapy in preventing clot formation.
A client with a head injury reports severe nausea. What is the nurse's priority action?
- A. Administer anti-nausea medication as prescribed.
- B. Prepare the client for a CT scan.
- C. Elevate the head of the bed and provide an emesis basin.
- D. Notify the healthcare provider immediately.
Correct Answer: D
Rationale: Severe nausea in a client with a head injury may be a sign of increased intracranial pressure. The nurse should notify the healthcare provider immediately to ensure timely intervention, as increased pressure can lead to further complications such as brain herniation. Administering anti-nausea medication or preparing for a CT scan may delay necessary treatment for the underlying cause of the nausea, which could be related to the head injury. Elevating the head of the bed and providing an emesis basin may help manage symptoms but should not be the priority over addressing the potential increase in intracranial pressure.
A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the nurse should be which of these statements?
- A. I am sorry. Referral information can only be provided by the client's health care providers.
- B. I can never give any information out by telephone. How do I know who you are?
- C. Since this is a referral, I can give you this information.
- D. I need to get the client's written consent before I release any information to you.
Correct Answer: D
Rationale: The correct answer is D: "I need to get the client's written consent before I release any information to you." In this scenario, the nurse must obtain the client's written consent before disclosing any information to the social worker. This process ensures compliance with privacy laws like HIPAA, which are designed to protect client confidentiality. Choice A is incorrect because it does not address the need for consent. Choice B is incorrect as it is unprofessional and does not focus on obtaining consent. Choice C is incorrect as it suggests information can be shared without consent, which goes against privacy laws.
A male client admitted for schizophrenia is noted to be diaphoretic and pacing the hallway. What is the most important intervention?
- A. Take the client's temperature and blood pressure.
- B. Encourage the client to rest.
- C. Plan an activity involving physical exercise.
- D. Carefully observe the client throughout the shift.
Correct Answer: D
Rationale: In this scenario, the most important intervention for a male client with schizophrenia who is diaphoretic and pacing the hallway is to carefully observe the client throughout the shift. Diaphoresis and pacing can be indicators of agitation or distress in clients with schizophrenia. Careful observation is crucial to monitor the client's safety, assess for any potential escalation of symptoms, and provide timely intervention if needed. Taking the client's temperature and blood pressure (Choice A) may not address the immediate need for safety and observation. Encouraging the client to rest (Choice B) may not be effective if the client is agitated. Planning an activity involving physical exercise (Choice C) could potentially exacerbate the situation rather than addressing the immediate need for observation and safety.
The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective?
- A. We will call the health care provider if the child develops acne.
- B. Our child should brush and floss carefully after every meal.
- C. We will skip the next dose if vomiting or fever occur.
- D. When our child is seizure-free for 6 months, we can stop the medication.
Correct Answer: B
Rationale: Phenytoin can cause gingival hyperplasia, so good oral hygiene is important to prevent complications.