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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To improve overall health, the nurse should place highest priority on assisting a client to make lifestyle changes for which of the following habits?
- A. Drinking a six-pack of beer each day
- B. Eating an occasional chocolate bar
- C. Exercising twice a week
- D. Using relaxation exercises to deal with stress
Correct Answer: A
Rationale: Daily heavy alcohol consumption poses significant health risks (liver disease, cardiovascular issues), making it the highest priority for lifestyle change.
A patient has recently been prescribed Albuterol. Which of the following changes are not associated with Albuterol?
- A. Tachycardia
- B. Hypertension
- C. Bronchodilation
- D. Sensory changes
Correct Answer: D
Rationale: Tachycardia, hypertension, and bronchodilation can all occur with Albuterol.
Which of the following home-care strategies is most likely to negatively impact the body image of a client with Cushing's syndrome?
- A. providing safety measures to prevent falls
- B. taking medications as prescribed
- C. wearing a medical ID indicating Cushing's syndrome
- D. having regular health assessments
Correct Answer: C
Rationale: All of the strategies listed are included in home care for the client with Cushing's syndrome. Choice 3 is the best answer because wearing a medical ID is a visible sign that something is wrong and a constant reminder to the client that he or she has a loss of body function. Choice 1 might enhance body image because it prevents falls that could cause further injury and debilitation. Taking medications as prescribed should enhance body image because it decreases the symptoms present. Having regular health assessments indicates an enhanced body image because it signals the desire to take care of the body and keep it at its best.
A nurse has been assigned a patient who has recently been diagnosed with Guillain-Barre' Syndrome. Which of the following statements is the most applicable when discussing the impairments with Guillain-Barre' Syndrome with the patient?
- A. Guillain-Barre' Syndrome gets better after 5 years in almost all cases.
- B. Guillain-Barre' Syndrome causes limited sensation in the abdominal region.
- C. Guillain-Barre' Syndrome causes muscle weakness in the legs.
- D. Guillain-Barre' Syndrome does not affect breathing in severe cases.
Correct Answer: C
Rationale: Muscle weakness in the lower extremities is found in acute cases of Guillain-Barre' Syndrome.
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.