Nokea
Which information is most appropriate to include in the discharge instructions for the client who has undergone a cataract extraction?Select all that apply.
- A. Avoid bending over from the waist.
- B. Sleep with the head slightly elevated.
- C. Wash hands before applying eye drops
- D. Sleep with the head elevated
Correct Answer: A,B,C,D
Rationale: Avoiding bending and elevating the head reduce intraocular pressure and promote healing.
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The nurse is caring for a client diagnosed with squamous cell skin cancer and writes a psychosocial problem of 'fear.' Which nursing interventions should be included in the plan of care?
- A. Explain to the client that the fears are unfounded.
- B. Encourage the client to verbalize the feeling of being afraid.
- C. Have the HCP discuss the client’s fear with the client.
- D. Instruct the client regarding all planned procedures.
Correct Answer: B
Rationale: Verbalizing fear helps address anxiety and promotes coping. Dismissing fears, deferring to HCP, or procedure instruction are less therapeutic.
The nurse is teaching a class on how to prevent Lyme disease. Which intervention should be included in the discussion?
- A. Instruct the clients to wear dark clothes when hunting.
- B. Use a sunscreen of at least SPF 30 when outside.
- C. Avoid dense undergrowth when in a wooded area.
- D. Do not use any type of insect repellant when deer hunting.
Correct Answer: C
Rationale: Avoiding dense undergrowth reduces tick exposure, preventing Lyme disease. Dark clothes attract ticks, sunscreen is irrelevant, and insect repellent is recommended.
The client is being discharged after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client’s mental health?
- A. Encourage the client to stay at home as much as possible.
- B. Discuss the importance of not relying on the family for needs.
- C. Tell the client to remember that changes in lifestyle take time.
- D. Instruct the client to discuss feelings only with the therapist.
Correct Answer: C
Rationale: Acknowledging lifestyle changes promotes mental health by fostering realistic expectations. Isolation, independence from family, or limiting discussions hinder recovery.
Which other assessment finding is most indicative of an infection in the external ear?
- A. Foul-smelling drainage
- B. Scarred tympanic membrane
- C. Diminished hearing
- D. Enlarged lymph nodes
Correct Answer: A
Rationale: Foul-smelling drainage is a hallmark of external ear infections.
Which finding in the health history would the nurse expect of a client with otosclerosis?
- A. Hearing loss beginning in childhood
- B. Upper respiratory infections with high fevers
- C. One or more relatives similarly diagnosed
Correct Answer: C
Rationale: Otosclerosis often has a familial component, with relatives affected.