Nokea
To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)
- A. Teach the client breathing exercises.
- B. Establish a regular bladder routine.
- C. Perform chest physiotherapy.
- D. Encourage use of incentive spirometer.
- E. Initiate passive range of motion exercises.
Correct Answer: A,C,D,E
Rationale: Breathing exercises, chest physiotherapy, incentive spirometer use, and passive range of motion exercises directly address respiratory function and mobility, reducing the risk of pulmonary complications in ALS by improving lung expansion, mobilizing secretions, and maintaining joint mobility.
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During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
- A. Corticosteroid cream was applied to eczema.
- B. A grandson and his new dog recently visited.
- C. An old friend with eczema came for a visit.
- D. Recently received an influenza immunization.
Correct Answer: B
Rationale: Exposure to a new dog may introduce allergens like dander, triggering an eczema flare-up, making this information critical for identifying the cause of the exacerbation.
While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the health care provider, the nurse should evaluate which laboratory value?
- A. Platelet count.
- B. Serum albumin.
- C. Neutrophil count.
- D. Blood pH level.
Correct Answer: C
Rationale: Neutrophil count is a measure of the body's immune response to infection. Neutrophils are the most abundant type of white blood cells and are the first line of defense against bacterial infections. A high neutrophil count can indicate an acute infection, such as that suggested by purulent drainage from burn wounds.
An adult woman with Grave's disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement?
- A. Teach the client relaxation techniques.
- B. Determine the client's food preferences.
- C. Maintain a patent intravenous site.
- D. Keep room temperature cool.
Correct Answer: C
Rationale: Maintaining a patent IV site allows administration of fluids, electrolytes, and nutrients, addressing the critical dehydration and malnutrition in Grave's disease, which takes precedence over other supportive measures.
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?
- A. Use incentive spirometer.
- B. Monitor urinary stream for decrease in output.
- C. Report when hematuria becomes pink tinged.
- D. Restrict physical activities.
Correct Answer: B
Rationale: Monitoring urinary stream for decreased output post-TUNA is essential to identify potential complications such as urinary retention, infection, or bleeding, ensuring timely intervention.
A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). Which information should the nurse provide?
- A. Obtain a prostate-specific antigen blood level test.
- B. Take vitamin supplements.
- C. Increase physical activity.
- D. Consume a high protein diet.
Correct Answer: C
Rationale: Increasing physical activity helps maintain a healthy weight and improves pelvic blood flow, reducing BPH risk factors, unlike PSA testing, supplements, or high-protein diets, which lack direct preventive benefits.