Nokea
What instruction should the nurse provide a pregnant client experiencing heartburn?
- A. Limit fluid intake between meals to prevent stomach over-distension
- B. Take an antacid at bedtime and when symptoms worsen
- C. Maintain an upright position for two hours after eating
- D. Eat small meals throughout the day to avoid a full stomach
Correct Answer: D
Rationale: The correct answer is D: 'Eat small meals throughout the day to avoid a full stomach.' Heartburn is common in pregnancy due to increased intra-abdominal pressure and hormonal changes. Consuming small, frequent meals prevents the stomach from becoming overly full, reducing the likelihood of acid reflux and heartburn. Choice A is incorrect because limiting fluid intake between meals may not significantly impact heartburn. Choice B is not ideal as antacids should be taken as directed by a healthcare provider, not just at bedtime or when symptoms worsen. Choice C is less effective advice, as maintaining an upright position after eating may not directly address the root cause of heartburn.
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An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client used to run a year ago, his spouse states that the client no longer runs but sits and watches television most of the day. Which is most important for the nurse to include in this client's plan of care for today?
- A. Assist the client in identifying goals for the day
- B. Encourage the client to participate in a team sport for one hour
- C. Schedule the client for a group session that focuses on self-esteem
- D. Help the client develop a list of daily affirmations
Correct Answer: A
Rationale: Assisting the client in identifying goals for the day is the most important aspect of the plan of care for a client with severe depression. Setting achievable daily goals helps engage the client in activities and promotes a sense of accomplishment, which can contribute to gradual improvement in their condition. Encouraging participation in team sports may be overwhelming for a client with severe depression as it requires a significant level of energy and motivation that the client may not possess at this time. Group sessions focusing on self-esteem and daily affirmations are beneficial interventions, but they may not have an immediate impact compared to setting achievable daily goals that can provide a sense of purpose and achievement for the client.
When assessing a client with acute asthma, the nurse is most likely to obtain which finding?
- A. Pursed lip breathing and clubbing of fingers
- B. Fever and a high-pitched inspiratory stridor
- C. A short expiratory phase and hemoptysis
- D. Cough and musical breath sounds on expiration
Correct Answer: D
Rationale: When assessing a client with acute asthma, a cough and wheezing or musical breath sounds on expiration are typical findings. Pursed lip breathing and clubbing of fingers (choice A) are not common in acute asthma but could be seen in chronic respiratory conditions. Fever and high-pitched inspiratory stridor (choice B) are more indicative of croup or epiglottitis. A short expiratory phase and hemoptysis (choice C) are not typical findings in acute asthma.
An elderly client with Alzheimer's disease is being admitted to a long-term care facility. The client's spouse expresses concern about the level of care the client will receive. What is the most appropriate response by the nurse?
- A. Reassure the spouse that the client will be well cared for and provide information about the facility's care practices.
- B. Inform the spouse that care will be adjusted based on the client's condition and needs.
- C. Advise the spouse to visit frequently to monitor the quality of care the client receives.
- D. Suggest that the spouse speak with other family members for reassurance.
Correct Answer: A
Rationale: The most appropriate response by the nurse in this situation is to reassure the spouse that the client will be well cared for and provide information about the facility's care practices. This response not only addresses the spouse's concerns directly but also helps in building trust and confidence in the care provided. Choice B is not ideal as it may cause unnecessary worry about the fluctuating care levels. Choice C puts the responsibility on the spouse to monitor care, which may not always be feasible or appropriate. Choice D deflects the concern to other family members instead of addressing the spouse's worries directly.
A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 mmHg and he admits that he has not been taking the prescribed medication because the drugs make him feel bad. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?
- A. Stroke secondary to hemorrhage
- B. Acute kidney injury due to glomerular damage
- C. Heart block due to myocardial damage
- D. Blindness secondary to cataracts
Correct Answer: A
Rationale: The correct answer is A: Stroke secondary to hemorrhage. Hypertension increases the risk of stroke due to the stress and damage it causes to blood vessels, which can lead to hemorrhage. Choice B is incorrect because acute kidney injury is more commonly associated with chronic uncontrolled hypertension, not acute elevations. Choice C is incorrect as heart block is not a direct consequence of hypertension. Choice D is incorrect as hypertension does not directly cause cataracts leading to blindness.
What action should the nurse implement for a female client with cancer who has a good appetite but experiences nausea whenever she smells food cooking?
- A. Encourage family members to cook meals outdoors and bring the cooked food inside
- B. Advise the client to replace cooked foods with a variety of different nutritional supplements
- C. Assess the client's mucus membranes and report the findings to the healthcare provider
- D. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting
Correct Answer: A
Rationale: The correct action for the nurse to implement is to encourage family members to cook meals outdoors and bring the cooked food inside. This strategy can help reduce the smell of cooking food and potentially alleviate the client's nausea triggered by food smells. Assessing the client's mucus membranes (choice C) is not directly related to the client's symptom of nausea triggered by food smells. Instructing the client to take an antiemetic before every meal (choice D) may not address the root cause of the issue, which is the smell of cooking food. Advising the client to replace cooked foods with nutritional supplements (choice B) does not address the immediate problem of food odors triggering nausea.