Nokea
The nurse reinforces discharge teaching to a client who had a total knee replacement 4 days ago. Which client statement indicates the need for additional teaching?
- A. I have to give myself shots in the belly because my spouse is afraid of needles?
- B. I have to use a walker because I cant bear any weight on this knee yet.
- C. I will call my health care provider if I get short of breath or sore or swollen below my knee
- D. The raised toilet seat makes it easier for me to get on and off the toilet by myself.
Correct Answer: A
Rationale: Self-administered anticoagulant injections require confirmation of correct technique, not spousal fear, indicating misunderstanding. Walker use , symptom reporting , and toilet aids are correct.
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A client with myocardial infarction underwent successful revascularization with stent placement, is now chest pain free, and will be attending cardiac rehabilitation as an outpatient. The client is embarrassed to talk to the health care provider about resuming sexual relations. What teaching should the nurse reinforce with this client?
- A. Client may be ready for sexual activity if no symptoms occur when climbing 2 flights of stairs
- B. Client will be ready for sexual activity after completion of cardiac rehabilitation
- C. It will be 6 months before the heart is healthy enough for sexual activity
- D. Medications such as sildenafil or tadalafil are available as prescriptions from the health care provider
Correct Answer: A
Rationale: Climbing two flights of stairs without symptoms indicates sufficient cardiac reserve for sexual activity. Waiting for rehab completion or 6 months is unnecessary, and medications require provider discussion.
A client with chronic bronchitis tells the home health nurse of being exhausted all day due to coughing all night and being unable to sleep. The client can feel thick mucus in the chest and throat. Which teaching can the nurse reinforce to help the client mobilize secretions and improve sleep? Select all that apply.
- A. Increase fluids to at least 8 glasses (2-3 L) of water a day
- B. Sleep with a cool mist humidifier
- C. Take prescribed guaifenesin cough medicine before bedtime
- D. Use abdominal breathing and the huff cough technique at bedtime
- E. Use pursed lip breathing during the night
Correct Answer: A,B,C,D
Rationale: Fluids , humidifiers , guaifenesin , and huff coughing thin and mobilize secretions. Pursed lip breathing aids exhalation, not secretion clearance.
A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse informs the child and family that the most important reason for this diet is to
- A. Promote healing and strengthen the immune system
- B. Provide a well balanced nutritional intake
- C. Stimulate increased peristalsis absorption
- D. Spare protein catabolism to meet metabolic needs
Correct Answer: D
Rationale: Spare protein catabolism to meet metabolic needs. A high-carbohydrate diet prevents protein breakdown for energy, allowing proteins to restore tissue.
A 2-month-old infant has been admitted to the hospital with suspected shaken baby syndrome (abusive head trauma). In reviewing the infant's chart, the nurse expects to encounter which of these clinical findings?
- A. A reported history of recent trauma
- B. Abdominal bruising
- C. External signs of trauma
- D. Irritability and vomiting
Correct Answer: D
Rationale: Shaken baby syndrome often presents with irritability and vomiting due to intracranial injury, without external trauma , abdominal bruising , or reported trauma .
At the geriatric day care program a client is crying and repeating 'I want to go home. Call my daddy to come for me.' The nurse should
- A. Inform the client that she must wait until the program ends at 5:00 pm to leave
- B. Give the client simple information about what she will be doing
- C. Tell the client you will call someone to come for her and suggest joining the exercise group while she waits
- D. Firmly direct the client to her assigned group activity
Correct Answer: C
Rationale: Tell the client you will call someone to come for her and suggest joining the exercise group while she waits. This uses comforting and distraction to reduce distress in dementia.