Nokea
The nurse provides home care instructions to a client diagnosed with Cushing's syndrome. The nurse determines that the client understands the hospital discharge instructions if the client makes which statement?
- A. I need to eat foods low in potassium.
- B. I need to check the color of my stools.
- C. I need to check the temperature of my legs twice a day.
- D. I need to take aspirin rather than acetaminophen for a headache.
Correct Answer: B
Rationale: Cushing's syndrome results in an increased secretion of cortisol. Cortisol stimulates the secretion of gastric acid, and this can result in the development of peptic ulcers and gastrointestinal bleeding. The client should be encouraged to eat potassium-rich foods to correct the hypokalemia that occurs with this disorder. Cushing's syndrome does not affect temperature changes in the lower extremities. Aspirin can increase the risk for gastric bleeding and skin bruising.
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The nurse is teaching a newly diagnosed client about Crohn's disease. The nurse understands which barriers may prevent effective client learning? Select all that apply.
- A. language barriers
- B. motivation to learn
- C. lack of a support system
- D. adequate financial resources
- E. cognitive dysfunction, such as schizophrenia
Correct Answer: A,B,C,E
Rationale: Language barriers, low motivation, lack of support, and cognitive dysfunction hinder learning. Adequate finances are not a barrier.
Cyclophosphamide is prescribed for the client diagnosed with breast cancer, and the nurse provides instructions to the client regarding the medication. Which statement by the client indicates the need for further teaching?
- A. If I lose my hair, it will grow back.
- B. If I develop a sore throat, I should notify the doctor.
- C. I need to limit my fluid intake while taking this medication.
- D. I need to avoid contact with anyone who recently received a live virus vaccine.
Correct Answer: C
Rationale: Cyclophosphamide can cause hemorrhagic cystitis, requiring copious fluid intake (2–3 liters/day) to prevent it, not fluid restriction. Hair regrowth, reporting sore throat (indicating infection), and avoiding live virus vaccine contacts are correct due to immunosuppression.
When preparing the client with a spinal cord injury who is experiencing bladder spasms and reflex incontinence for discharge to home, the nurse should provide which instruction to prevent the problem?
- A. Avoid caffeine in your diet.
- B. Take your temperature every day.
- C. Limit your fluid intake to 1000 mL per 24 hours.
- D. Catheterize yourself every 2 hours as needed to prevent spasm.
Correct Answer: A
Rationale: Caffeine in the diet can contribute to bladder spasms and reflex incontinence; thus, it should be eliminated in the diet of the client with a spinal cord injury. The self-monitoring of the temperature is useful to detect infection, but it does nothing to alleviate bladder spasms. Limiting fluid intake does not prevent spasm, and it could place the client at further risk for urinary tract infection. Self-catheterization every 2 hours is too frequent and serves no useful purpose.
Which factors increase the risk for hypothermia in an older client? Select all that apply.
- A. Burns
- B. Anemia
- C. Alcohol abuse
- D. Hypoglycemia
- E. Hyperthyroidism
- F. Poor thermoregulation
Correct Answer: A,B,C,D,F
Rationale: The median oral temperature of an older client is 96.8^{\circF}\left(36^{\circC}\right) . Environmental temperatures below 65^{\circF}\left(18^{\circC}\right) may cause a serious drop in core body temperature to 95^{\circF}\left(35^{\circC}\right) or less in the older client. Numerous factors increase the risk of hypothermia in the older client, including conditions that increase heat loss (e.g., burns); conditions that decrease heat production such as hypothyroidism, hypoglycemia, or anemia; medications or substances that interfere with thermoregulation, such as alcohol; or thermoregulatory impairment (failure to sense cold).
The nurse has provided instructions to a new mother with a urinary tract infection regarding foods and fluids to consume that will acidify the urine. The nurse determines that further teaching is needed if the mother indicates that which fluid will acidify the urine?
- A. Prune juice
- B. Apricot juice
- C. Cranberry juice
- D. Carbonated drinks
Correct Answer: D
Rationale: Acidification of the urine inhibits the multiplication of bacteria. Carbonated drinks should be avoided because they increase urine alkalinity. Fluids that acidify the urine include prune, apricot, and cranberry juice.