Nokea
The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspects of this care is/are
- A. sedation as needed to prevent exhaustion
- B. antibiotic therapy for 10 to 14 days
- C. humidified air and increased oral fluids
- D. antihistamines to decrease allergic response
Correct Answer: C
Rationale: humidified air and increased oral fluids. The most important aspects of home care for a child with acute spasmodic croup are humidified air and increased oral fluids. Moisture soothes inflamed membranes. Adequate systemic hydration aids in mucociliary clearance and keeps secretions thin, white, watery, and easily removed with minimal coughing.
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The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?
- A. Piercing the plastic of the ostomy pouch with a pin to vent the flatus
- B. Opening the bottom of the pouch, allowing the flatus to be expelled
- C. Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape
- D. Assisting the client to ambulate to reduce the flatus in the pouch
Correct Answer: B
Rationale: Opening the bottom of the pouch, allowing the flatus to be expelled, is the correct way to vent a 1-piece drainable ostomy pouch.
A disoriented male client reveals that the client has a self-care deficit (feeding).
Which of the following would indicate to the nurse that the client has made a positive response to the plan of care?
- A. Client explains the relationship between weight loss and change in mental status.
- B. Client identifies the basic four food groups.
- C. Client states he needs to drink more water.
- D. Client feeds self when the nurse stays with him and cues him.
Correct Answer: D
Rationale: Strategy: Determine the outcome of each answer choice. (1) would not be realistic in a client who is disoriented (2) would not be realistic in a client who is disoriented (3) would not be realistic in a client who is disoriented (4) correct-disoriented client who is not able to be an independent self-care agent will need cuing from the nurse to accomplish self-feeding
A client with severe multiple trauma injuries from a motor vehicle accident.
After stabilizing a client with severe multiple trauma injuries from a motor vehicle accident, which of the following actions by the nurse is BEST?
- A. Limit visiting hours to promote optimal rest.
- B. Arrange for clergy to visit with the client and family as requested.
- C. Arrange for a psychologist to visit with the family.
- D. Arrange for the family to meet with a social worker to discuss financial aid.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) inappropriate (2) correct-would provide the appropriate spiritual support necessary during a crisis (3) inappropriate for the data given in the situation (4) inappropriate for the data given in the situation
An adult male developed diabetes insipidus following a craniotomy.
Which of the following statements, if made by the client, would indicate that further teaching is needed?
- A. I should keep a daily record of my fluid intake and how much I go to the bathroom.
- B. I should call my doctor if I seem thirsty a lot and my urine specific gravity is less than 1.005.
- C. I should weigh myself every day and drink less fluid if I gain more than 5 lb over a week.
- D. I will need to take the nose spray medication for the rest of my life.
Correct Answer: C
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) disorder or water metabolism caused by deficiency of ADH (antidiuretic hormone) by pituitary gland, symptoms are increased urinary output (4-30 L/24 h), dilute urine with specific gravity less than 1.005 (2) normal specific gravity 1.003-1.030 (3) correct-weight gain should be reported to physician, may need medication adjusted (4) desmopressin (DDAVP) nasally or SQ required for remainder of life
A newly admitted client is exhibiting signs of severe anxiety. She is pacing back and forth and has difficulty concentrating on the nurse's questions. What nursing action is most appropriate at this time?
- A. Tell the client to sit down and get control of herself
- B. Leave the room until she regains control
- C. Whisper to her that everything will be all right
- D. Attend to her behavior and direct her to a quiet area
Correct Answer: D
Rationale: Directing the client to a quiet area reduces stimuli, helping manage severe anxiety. Commands, leaving, or whispering are ineffective or dismissive.