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The nurse notes that a large number of clients reporting the presence of flulike symptoms are being seen in the clinic. Which recommendations should the nurse provide to these clients to minimize their risk for further illness? Select all that apply.
- A. Get plenty of rest.
- B. Increase intake of liquids.
- C. Get a flu shot immediately.
- D. Take antipyretics for fever.
- E. Consume a well-balanced diet.
Correct Answer: A,B,D,E
Rationale: Treatment for the flu includes getting rest, drinking fluids, and taking in nutritious foods and beverages. Medications such as antipyretics and analgesics may also be used for symptom management. Immunizations against influenza are a prophylactic measure and are not used to treat flu symptoms.
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The nurse is developing a care plan for a client experiencing urge urinary incontinence. Which interventions would be helpful for this type of incontinence? Select all that apply.
- A. Surgery
- B. Bladder retraining
- C. Scheduled toileting
- D. Dietary modifications
- E. Pelvic muscle exercises
- F. Intermittent catheterization
Correct Answer: B,C,D,E
Rationale: Urge incontinence is the involuntary passage of urine after a strong sense of the urgency to void. It is characterized by urinary urgency, often with frequency (more often than every 2 hours); bladder spasm or contraction; and voiding in either small amounts (less than 100 mL) or large amounts (greater than 500 mL). It can be caused by decreased bladder capacity, irritation of the bladder stretch receptors, infection, and alcohol or caffeine ingestion. Interventions to assist the client with urge incontinence include bladder retraining, scheduled toileting, dietary modifications such as eliminating alcohol and caffeine intake, and pelvic muscle exercises to strengthen the muscles. Surgery and urinary catheterization are invasive measures and will not assist in the treatment of urge incontinence.
The nurse is assessing the casted extremity of a client for signs of infection. Which finding is indicative of the presence of an infection?
- A. Dependent edema
- B. Diminished distal pulse
- C. Coolness and pallor of the skin
- D. Presence of warm areas on the cast
Correct Answer: D
Rationale: Manifestations of infection under a casted area include a musty odor or purulent drainage from the cast or the presence of areas on the cast that are warmer than others. The primary health care provider should be notified if any of these occur. Dependent edema, diminished arterial pulse, and coolness and pallor of the skin all signify impaired circulation in the distal extremity.
The nurse is caring for a client diagnosed with active tuberculosis who is prescribed rifampin therapy. The nurse instructs the client to expect which side effect of this medication?
- A. Green urine
- B. Yellow sclera
- C. Orange secretions
- D. Clay-colored stools
Correct Answer: C
Rationale: Rifampin is an antituberculosis medication. Secretions will become orange in color as a result of the rifampin. The client should be instructed that this side effect will likely occur.
A client experiencing trigeminal neuralgia (tic douloureux) asks the nurse for a snack and something to drink. Which is the best selection the nurse should provide for the client?
- A. Hot cocoa with honey and toast
- B. Vanilla pudding and lukewarm milk
- C. Hot herbal tea with graham crackers
- D. Iced coffee and peanut butter and crackers
Correct Answer: B
Rationale: Because mild tactile stimulation of the face of clients with trigeminal neuralgia can trigger pain, the client needs to eat or drink lukewarm, nutritious foods that are soft and easy to chew. Extremes of temperature will cause trigeminal pain.
Which interventions should the emergency department nurse prepare for in the care of a child with croup and epiglottitis? Select all that apply.
- A. Obtaining a chest x-ray
- B. Obtaining a throat culture
- C. Monitoring pulse oximetry
- D. Maintaining a patent airway
- E. Providing humidified oxygen
- F. Administering antipyretics and antibiotics
Correct Answer: A,C,D,E,F
Rationale: Epiglottitis is an acute inflammation and swelling of the epiglottis and surrounding tissue. It is a life-threatening, rapidly progressive condition that may cause complete airway obstruction within a few hours of onset. The most reliable diagnostic sign is an edematous, cherry-red epiglottis. Some interventions include obtaining a chest x-ray film, monitoring pulse oximetry, maintaining a patent airway, providing humidified oxygen, and administering antipyretics and antibiotics. The child may also require intubation and mechanical ventilation. The primary concern in a child with epiglottitis is the development of complete airway obstruction. Therefore, the child's throat is not examined or cultured because any stimulation with a tongue depressor or culture swab could trigger complete airway obstruction.