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What would be the nurse's best response to the client's expressed feelings of isolation as a result of having hepatitis?
- A. Don't worry. It's normal to feel that way.'
- B. Your friends are probably afraid of contracting hepatitis from you.'
- C. I'm sure you're imagining that!'
- D. Tell me more about your feelings of isolation.'
Correct Answer: D
Rationale: Encouraging the client to express feelings (D) fosters therapeutic communication and addresses emotional needs. Dismissing feelings (A, C) or assuming others' fears (B) is non-therapeutic and unhelpful.
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The nurse should teach the client with Addison's disease that the adverse effect of bronze-colored skin is thought to be caused by which of the following?
- A. Hypersensitivity to sun exposure.
- B. Increased serum bilirubin level.
- C. Adverse effects of the glucocorticoid therapy.
- D. Increased secretion of adrenocorticotropic hormone (ACTH).
Correct Answer: D
Rationale: Bronze-colored skin in Addison's disease results from increased ACTH, which stimulates melanin production.
Which foods should the nurse encourage a client with diverticulosis to incorporate into the diet? Select all that apply.
- A. Bran cereal.
- B. Broccoli.
- C. Tomato juice.
- D. Navy beans.
- E. Cheese.
Correct Answer: A,B,D
Rationale: Bran cereal (A), broccoli (B), and navy beans (D) are high-fiber foods that help prevent complications in diverticulosis by promoting regular bowel movements. Tomato juice (C) and cheese (E) are not high in fiber. CN: Physiological adaptation; CL: Create
A client is admitted to the hospital with peripheral vascular disease (PVD) of the lower extremities. He is scheduled for an amputation of the left leg. The client says, 'I've really tried to manage my condition well.' Which of the following routines should the nurse evaluate as having been appropriate for him?
- A. Resting with his legs elevated above the level of his heart
- B. Walking slowly but steadily for 30 minutes twice a day
- C. Minimizing activity
- D. Wearing antiembolism stockings at all times when out of bed
Correct Answer: B
Rationale: Walking slowly but steadily for 30 minutes twice a day promotes collateral circulation and maintains muscle strength in PVD, an appropriate self-management strategy. Elevating legs above the heart is contraindicated in arterial insufficiency, minimizing activity worsens ischemia, and antiembolism stockings are more suited for venous issues.
When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which of the following indicate that the client is following instructions?
- A. The skin around the stoma is red.
- B. The urine is a deep yellow.
- C. There is no odor present.
- D. The seal around the stoma is intact.
Correct Answer: C,D
Rationale: No odor and an intact seal indicate frequent emptying, preventing urine leakage and skin irritation. Red skin or deep yellow urine suggest inadequate care or dehydration.
A client undergoes a laparoscopic cholecystectomy. Which of the following dietary instructions should the nurse give the client immediately after surgery?
- A. You cannot eat or drink anything for 24 hours.
- B. You may resume your normal diet the day after your surgery.
- C. Drink liquids today and eat lightly for a few days.
- D. You can progress from a liquid to a bland diet as tolerated.
Correct Answer: C
Rationale: Post-laparoscopic cholecystectomy, patients typically start with clear liquids and progress to light meals to avoid gastrointestinal stress. Option C is most appropriate. Option A is too restrictive, B is premature, and D is less specific.