Nokea
What action will the nurse plan to take for a 40-year-old patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder?
- A. Decrease the patient's evening fluid intake.
- B. Teach the patient how to use the Cred method.
- C. Suggest the use of adult incontinence briefs for nighttime only.
- D. Assist the patient to the commode every 2 hours during the day.
Correct Answer: B
Rationale: For a 40-year-old patient with multiple sclerosis experiencing urinary retention due to a flaccid bladder, teaching the Cred method is the appropriate action. The Cred method involves applying manual pressure over the bladder to aid in bladder emptying. Decreasing fluid intake is not the correct approach as it will not address the underlying issue of bladder emptying and may lead to dehydration and urinary tract infections. Using adult incontinence briefs only addresses the symptom of incontinence without addressing the bladder emptying problem. Assisting the patient to the commode every 2 hours does not actively address the issue of improving bladder emptying as effectively as teaching the Cred method.
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The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first?
- A. Assist the patient to sit upright in a chair.
- B. Splint the patient's chest during coughing.
- C. Medicate the patient with prescribed morphine.
- D. Observe the patient use the incentive spirometer.
Correct Answer: C
Rationale: The correct answer is to medicate the patient with prescribed morphine. A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain, which can worsen with deep breathing and coughing. The priority is to address the incisional pain to facilitate effective coughing and deep breathing, which are essential for clearing the airways and preventing complications. Assisting the patient to sit upright, splinting the patient's chest during coughing, and observing the patient using the incentive spirometer are all appropriate interventions to improve airway clearance, but they should be implemented after addressing the incisional pain with medication.
A client in end-stage renal disease is receiving peritoneal dialysis at home. The nurse must educate the client about potential complications associated with this procedure. All of the following are complications associated with peritoneal dialysis EXCEPT:
- A. Hypotriglyceridemia
- B. Abdominal hernia
- C. Anorexia
- D. Peritonitis
Correct Answer: A
Rationale: Peritoneal dialysis poses risks of various complications, including abdominal hernia, anorexia, peritonitis, and other issues. However, hypotriglyceridemia is not a common complication associated with peritoneal dialysis. The nurse should focus on educating the client about the risks of developing peritonitis, abdominal hernias, anorexia, low back pain, and abdominal bleeding. Monitoring triglyceride levels is essential for managing lipid disorders but is not directly linked to peritoneal dialysis complications.
A client presents with symptoms of a sore throat, swollen lymph nodes in the neck, fever, chills, and extreme fatigue. Based on these symptoms, which of the following illnesses could the nurse consider for this client?
- A. Methicillin-resistant Staphylococcus aureus (MRSA)
- B. Hepatitis B
- C. Infectious mononucleosis
- D. Norovirus infection
Correct Answer: C
Rationale: Infectious mononucleosis is a viral disease caused by the Epstein-Barr virus. The symptoms of sore throat, fever, chills, swollen lymph nodes, and extreme fatigue are characteristic of infectious mononucleosis. The diagnosis is confirmed through the client's history and blood tests for the Epstein-Barr virus. Methicillin-resistant Staphylococcus aureus (MRSA) presents with localized skin infections, not the systemic symptoms described. Hepatitis B typically presents with jaundice, abdominal pain, and liver inflammation, not the symptoms described. Norovirus infection commonly causes gastrointestinal symptoms like vomiting and diarrhea, not the symptoms presented by the client.
An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?
- A. Arrange for a friend to administer the medication on schedule.
- B. Give the patient written instructions about how to take the medications.
- C. Teach the patient about the high risk for infecting others unless treatment is followed.
- D. Arrange for a daily noon meal at a community center where the drug will be administered
Correct Answer: D
Rationale: Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen for a homeless patient with active tuberculosis. By arranging a daily noon meal at a community center where the drug will be administered, the nurse ensures that the patient is available to receive the medication and can directly observe the patient taking it. This method helps address the challenges faced by homeless individuals, such as lack of a stable living situation. The other options, such as having a friend administer the medication, giving written instructions, or educating about infecting others, may not be as effective in ensuring adherence, especially in the case of a homeless individual with alcoholism.
The pediatric nurse caring for a 3-year-old child with cerebral palsy (CP) prepares a home care teaching plan for the caregivers on discharge. Which items will the nurse include in the teaching plan? (Select one that does not apply.)
- A. Apply splints and braces to facilitate muscle control.
- B. Buy toys that are appropriate for the child's abilities.
- C. Encourage the child to perform self-care tasks.
- D. Use skeletal muscle relaxants for short-term control.
Correct Answer: D
Rationale: When developing a discharge teaching plan for a child with cerebral palsy (CP), the nurse should focus on strategies to enhance the child's independence and functional abilities. Choices A, B, and C are appropriate interventions to include in the teaching plan for a child with CP. Applying splints and braces can help facilitate muscle control and improve body functioning. Buying toys that are appropriate for the child's abilities can promote engagement and development. Encouraging the child to perform self-care tasks fosters independence and skill development. However, the use of skeletal muscle relaxants for short-term control is not typically a part of routine care for pediatric patients with CP. These medications are usually reserved for specific situations and are not a standard component of home care teaching plans for children with CP.