Nokea
The nurse is teaching a client who is preparing for discharge from the hospital after a total hip arthroplasty. Which statement by the client indicates the need for further teaching?
- A. I need to avoid twisting my body when I am standing.'
- B. I need to check my incision every day for signs of infection.'
- C. I should not sit in one position for a prolonged period of time.'
- D. I can cross my legs if it is more comfortable for me when I sit.'
Correct Answer: D
Rationale: After total hip arthroplasty, there are several measures that the client needs to take to ensure healing and protection and safety to the surgical site. Some hip precautions include not standing or sitting for prolonged periods of time, avoiding crossing the legs beyond the midline of the body, avoiding bending the hips more than 90 degrees, and avoiding twisting the body when standing. The client is also instructed to check the incision site daily for signs of infection (redness, heat, or drainage) and to contact the primary health care provider if signs of infection are noted.
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The mother of a child with celiac disease asks the nurse how long a special diet is necessary. The nurse provides which instruction to the mother to promote dietary compliance?
- A. A gluten-free diet will need to be followed for life.
- B. A lactose-free diet will need to be followed temporarily.
- C. Added dietary sodium will help prevent episodes of celiac crisis.
- D. Supplemental vitamins, iron, and folate will prevent complications.
Correct Answer: A
Rationale: Celiac disease is characterized by intolerance to gluten, the protein component of wheat, barley, rye, and oats. The main nursing consideration with celiac disease is helping the child adhere to dietary management. The treatment of celiac disease consists primarily of dietary management with a gluten-free diet. Options 2 and 4 are true statements, but they do not answer the question that the client is asking. Children with untreated celiac disease may have lactose intolerance, which usually improves with gluten withdrawal. Additional sodium does not prevent celiac crisis. Low levels of potassium, calcium, and magnesium are most likely to be present. Nutritional deficiencies resulting from malabsorption are treated with appropriate supplements.
A client is given a prescription for an antipsychotic medication. The nurse instructs the client and family to report any signs/symptoms of pseudoparkinsonism and tells the family to monitor for what effects indicative of this medication complication?
- A. Tremors and hyperpyrexia
- B. Motor restlessness and aphasia
- C. Stooped posture and a shuffling gait
- D. Muscle weakness and decreased salivation
Correct Answer: C
Rationale: Pseudoparkinsonism is a common extrapyramidal side effect of antipsychotic medications. This condition is characterized by a stooped posture, a shuffling gait, a masklike facial appearance, drooling, tremors, and pill-rolling motions of the fingers. Hyperpyrexia is characteristic of the extrapyramidal side effect of neuroleptic malignant syndrome. Motor restlessness, aphasia, muscle weakness, and decreased salivation are not characteristic of pseudoparkinsonism.
A client is diagnosed with thromboangiitis obliterans (Buerger's disease). The nurse places priority on teaching the client about modifications of which risk factor related to this disorder?
- A. Exposure to heat
- B. Cigarette smoking
- C. Diet low in vitamin C
- D. Excessive water intake
Correct Answer: B
Rationale: Buerger's disease is an occlusive disease of the median small arteries and veins. It occurs predominantly among men who are more than 40 years old who smoke cigarettes. A familial tendency is noted, but cigarette smoking is consistently a risk factor. Symptoms of the disease improve with smoking cessation. Exposure to heat, diet low in vitamin C, and excessive water intake are not risk factors.
A client weighs 165 pounds (75 kg) at admission. During hospitalization, the nurse determines that the client is maintaining adequate nutritional status if the client's weight is how many pounds?
- A. 153 pounds (69.5 kg)
- B. 155 pounds (70.4 kg)
- C. 157 pounds (71.3 kg)
- D. 160 pounds (72.7 kg)
Correct Answer: D
Rationale: Adequate nutritional status is maintained if the client's weight remains within 5 pounds of the baseline (165 pounds), so 160 to 165 pounds is acceptable. Weights below 160 pounds indicate significant loss, suggesting inadequate nutrition.
The community health is conducting a health screening clinic. The nurse interprets that which client participating in the screening is the highest priority client to provide instruction to lower the risk of developing respiratory disease?
- A. A smoker who works in an acute care hospital
- B. A person who works with lawn care pesticides
- C. A person who does woodworking as a hobby for 8 years
- D. A smoker who has cracked asbestos lining on the basement pipes
Correct Answer: D
Rationale: The client who smokes and has exposure to cracked asbestos lining is at the highest risk for respiratory disease due to the combined effects of smoking and asbestos, both potent lung irritants. Smoking alone or other exposures (pesticides, woodworking) pose risks, but the dual exposure in option D is the most severe.