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When preparing the client with a spinal cord injury who is experiencing bladder spasms and reflex incontinence for discharge to home, the nurse should provide which instruction to prevent the problem?
- A. Avoid caffeine in your diet.
- B. Take your temperature every day.
- C. Limit your fluid intake to 1000 mL per 24 hours.
- D. Catheterize yourself every 2 hours as needed to prevent spasm.
Correct Answer: A
Rationale: Caffeine in the diet can contribute to bladder spasms and reflex incontinence; thus, it should be eliminated in the diet of the client with a spinal cord injury. The self-monitoring of the temperature is useful to detect infection, but it does nothing to alleviate bladder spasms. Limiting fluid intake does not prevent spasm, and it could place the client at further risk for urinary tract infection. Self-catheterization every 2 hours is too frequent and serves no useful purpose.
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The clinic nurse provides home care instructions to a mother regarding the care of her child who is diagnosed with croup. Which statement by the mother indicates the need for further instructions?
- A. I will give Tylenol for the fever.
- B. I will give cough syrup every night at bedtime.
- C. Sips of warm fluids during a croup attack will help.
- D. I will place a cool-mist humidifier next to my child's bed.
Correct Answer: B
Rationale: The mother needs to be instructed that cough syrup and cold medicines should not be administered because they may dry and thicken secretions, worsening croup symptoms. Acetaminophen (Tylenol) is appropriate for reducing fever. Sips of warm fluids help relax the vocal cords and thin mucus. A cool-mist humidifier is recommended to keep the air moist and reduce airway irritation.
A client is being discharged from the hospital after a bronchoscopy that was performed a day earlier. After the discharge teaching, the client makes the following statements to the nurse. Which statement should the nurse identify as indicating a need for further teaching?
- A. I will stop smoking my cigarettes.
- B. I can expect to cough up bright red blood.
- C. I will get help immediately if I start having trouble breathing.
- D. I will use the throat lozenges as directed by my doctor until my sore throat goes away.
Correct Answer: B
Rationale: After bronchoscopy, expectorated secretions are inspected for hemoptysis, and if the client expectorates bright red blood, the primary health care provider is to be notified. The client needs to avoid smoking. The client should be observed for signs/symptoms of respiratory distress, including dyspnea, changes in respiratory rate, the use of accessory muscles, and changes in or absent lung sounds. A sore throat is common, and lozenges would be helpful to alleviate it.
A mother brings her 6-month-old baby to the nurse practitioner for a routine well-baby check. Which behavior reported by the mother is concerning to the nurse?
- A. looks at self in a mirror
- B. brings things to mouth
- C. does not laugh or make squealing sounds
- D. begins to sit without support
Correct Answer: C
Rationale: Lack of laughing or squealing at 6 months suggests a developmental delay, as these are expected social behaviors. Other behaviors are age-appropriate.
Which factors increase the risk for hypothermia in an older client? Select all that apply.
- A. Burns
- B. Anemia
- C. Alcohol abuse
- D. Hypoglycemia
- E. Hyperthyroidism
- F. Poor thermoregulation
Correct Answer: A,B,C,D,F
Rationale: The median oral temperature of an older client is 96.8^{\circF}\left(36^{\circC}\right) . Environmental temperatures below 65^{\circF}\left(18^{\circC}\right) may cause a serious drop in core body temperature to 95^{\circF}\left(35^{\circC}\right) or less in the older client. Numerous factors increase the risk of hypothermia in the older client, including conditions that increase heat loss (e.g., burns); conditions that decrease heat production such as hypothyroidism, hypoglycemia, or anemia; medications or substances that interfere with thermoregulation, such as alcohol; or thermoregulatory impairment (failure to sense cold).
The nurse teaches a client at risk for coronary artery disease about lifestyle changes needed to reduce his risks. The nurse determines that the client understands these necessary lifestyle changes if the client makes which statements?
- A. I will attempt to stop smoking.
- B. I will be sure to include some exercise such as walking in my daily activities.
- C. I will work at losing some weight so that my weight is at normal range for my age.
- D. I will limit my sodium intake every day and avoid eating high-sodium foods such as hot dogs.
- E. It is acceptable to eat red meat and cheese every day as I have been doing, as long as I cut down on the butter.
- F. I will schedule regular doctor appointments for physical examinations and monitoring my blood pressure.
Correct Answer: B,C,D,F
Rationale: Coronary artery disease affects the arteries that provide blood, oxygen, and nutrients to the myocardium. Modifiable risk factors include elevated serum cholesterol levels, cigarette smoking, hypertension, impaired glucose tolerance, obesity, physical inactivity, and stress. The client is instructed to stop smoking (not cut down), and the nurse should provide the client with resources to do so. The client is also instructed to maintain a normal weight and include physical activity in the daily schedule. The client needs to limit sodium intake and foods high in cholesterol, including red meat and cheese. The client must follow up with regular primary health care provider appointments for physical examinations and monitoring blood pressure.