Nokea
The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions?
- A. It is normal for your breasts to be tender. You should call the physician if you also have redness and fatigue.
- B. Because your baby was delivered vaginally, you might have to urinate more frequently.
- C. It is normal to run a low-grade temperature for a few days. If it is higher than 100°F, call your physician.
- D. Be sure to call your physician if your vaginal discharge becomes bright red.
Correct Answer: D
Rationale: The vaginal discharge after birth is called lochia, and it changes from red (rubra) to serosa (clear) on the third postpartum day. If it returns to red or contains clots, it could signal impending hemorrhage or infection and the physician should be notified.
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Broccoli, oranges, dark greens, and dark yellow vegetables can be eaten to:
- A. supplement vitamin pills.
- B. balance body molecules.
- C. cure many diseases.
- D. help improve body defenses.
Correct Answer: D
Rationale: Controversy over what types of food to eat and not eat is still under investigation. Certain foods can help improve body defenses to possibly prevent certain diseases.
If your patient is acutely psychotic, which of the following independent nursing interventions would not be appropriate?
- A. Conveying calmness with one on one interaction
- B. Recognizing and dealing with your own feelings to prevent escalation of the patient's anxiety level
- C. Encourage client participation in group therapy
- D. Listen and identify causes of their behavior
Correct Answer: C
Rationale: Acutely psychotic patients will disrupt group activities.
A 93 year-old female with a history of Alzheimer's Disease gets admitted to an Alzheimer's unit. The patient has exhibited signs of increased confusion and limited stability with gait. Moreover, the patient is refusing to use a w/c. Which of the following is the most appropriate course of action for the nurse?
- A. Recommend the patient remain in her room at all times.
- B. Recommend family members bring pictures to the patient's room.
- C. Recommend a speech therapy consult to the doctor.
- D. Recommend the patient attempt to walk pushing the w/c for safety.
Correct Answer: B
Rationale: Stimulation in the form of pictures may decrease signs of confusion.
A patient has suffered a left CVA and has developed severe hemiparesis resulting in a loss of mobility. The nurse notices on assessment that an area over the patient's left elbow appears as non-blanchable erythema and the skin is intact. The nurse should score the patient as having which of the following?
- A. Stage I pressure ulcer
- B. Stage II pressure ulcer
- C. Stage III pressure ulcer
- D. Stage IV pressure ulcer
Correct Answer: A
Rationale: Erythema with the skin intact can indicate a Stage I pressure ulcer.
When an elder client asks the nurse whether he will be capable of sexual activity in old age, the best response by the nurse is:
- A. Elder adults are psychologically and physically capable of engaging in sexual activity regardless of age-related changes.'
- B. If you haven't been sexually active throughout your life, you will not be able to participate in sexual activity in old age.'
- C. When intercourse isn't possible, many of your sexual needs can be met through intimacy and touch.'
- D. You might find it takes longer for you to achieve an erection, but you can maintain it for a longer time.'
Correct Answer: A
Rationale: To provide the best response, the nurse must identify what the elder is asking. Concern is being expressed about whether elders can engage in sexual activity. The most therapeutic response by the nurse is Choice 1. In this choice, the nurse acknowledges that elders can physically engage in sexual activity and have no psychological barriers to the same. All of the other choices contain facts but are not the best initial response. Choice 1 opens the conversation for the expression of further concerns about sexual issues.