Nokea
The nurse is teaching a female client who is experiencing urge incontinence how to manage her condition at home. Which statement by the client indicates a need for further explanation by the nurse?
- A. I will be cured in four weeks if I follow the bladder retraining instructions.
- B. I will perform the pelvic muscle exercises daily.
- C. I will wait five minutes once I get the urge to urinate to go to the bathroom.
- D. I will empty my bladder when I first get up in the morning.
Correct Answer: A
Rationale: Urge incontinence may not be cured in four weeks; bladder retraining aims to manage symptoms, not guarantee a cure, indicating a need for further teaching.
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The client has recently been diagnosed with diabetes. Which of the following indicates understanding of the management of diabetes?
- A. The client selects a balanced diet from the menu.
- B. The client can tell the nurse the normal blood glucose level.
- C. The client asks for brochures on the subject of diabetes.
- D. The client demonstrates correct insulin injection technique.
Correct Answer: D
Rationale: Demonstrating correct insulin injection technique indicates practical understanding and ability to manage diabetes effectively.
The nurse is preparing to administer levofloxacin (Levaquin) 400 mg orally to a client with a urinary tract infection. Which statement by the client requires further teaching by the nurse?
- A. I will need to wear sunscreen if I am outdoors.
- B. I need to finish all the medication, even if my symptoms go away.
- C. I should take my antacid right before my pill so I don't get heartburn.
- D. I need to check my pulse twice daily and call my doctor if I have new-onset irregular heartbeats.
Correct Answer: C
Rationale: Antacids can reduce levofloxacin absorption and should be taken at least 2 hours apart. Other statements are correct.
The nurse is working on a discharge teaching plan for a client prescribed phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI drug). The nurse knows teaching was successful if the client states,
- A. I will not be able to have wine and aged cheese anymore.'
- B. I should avoid all dairy products from now on.'
- C. Taking this medication with vitamin K-containing foods is dangerous.'
- D. I will need to decrease my dietary fiber now.'
Correct Answer: A
Rationale: MAOIs like phenelzine require avoiding tyramine-rich foods (e.g., wine, aged cheese) to prevent hypertensive crisis. Dairy, vitamin K, and fiber are not contraindicated.
The home health nurse is planning for the day's visits. Which client should be seen first?
- A. The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube
- B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension
- C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line
- D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
Correct Answer: B
Rationale: The 5-month-old with recent pneumonia is at high risk for complications, prioritizing their assessment.
The primary reason for rapid continuous rewarming of the area affected by frostbite is to:
- A. Lessen the amount of cellular damage
- B. Prevent the formation of blisters
- C. Promote movement
- D. Prevent pain and discomfort
Correct Answer: A
Rationale: Rapid rewarming minimizes cellular damage by restoring blood flow and preventing further tissue injury in frostbite.