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Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply.
- A. Dimming the lights at night
- B. Leaving the television on for diversion at night
- C. Opening the window blinds/shades in the morning
- D. Scheduling interventions and activities during the day when possible
- E. Turning off equipment alarms in the client's room at night
Correct Answer: A, C, D
Rationale: Dimming lights (A), opening blinds in the morning (C), and scheduling activities during the day (D) promote circadian rhythms and rest. Leaving the TV on (B) may disrupt sleep, and turning off alarms (E) compromises safety.
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Diphenoxylate hydrochloride with atropine sulfate (Lomotil) is prescribed for a client. The nurse knows that the drug is prescribed for which of these problems the client has?
- A. Diarrhea
- B. Hypertension
- C. Depression
- D. Tachycardia
Correct Answer: A
Rationale: Lomotil is an antidiarrheal, slowing intestinal motility to reduce diarrhea.
An adult who has newly diagnosed angina has been prescribed sublingual nitroglycerin. What should be included in the nurse's teaching about the medication? Select all that apply.
- A. Put the tablets under your tongue and let them dissolve.
- B. Keep the tablets in a dark glass container.
- C. You can take one tablet, and if you still have pain, you can take another tablet in 10 minutes.
- D. Be sure to take nitroglycerin while you are standing up.
- E. You may get a headache shortly after you take the medication,
- F. If your tongue tingles spit out the tablet.
Correct Answer: A,B,E
Rationale: Sublingual nitroglycerin is dissolved under the tongue, stored in dark glass to maintain potency, and may cause headaches as a side effect.
A community health nurse is preparing to administer influenza vaccines. Which clients can safely receive the live-attenuated, intranasal influenza vaccine? Select all that apply.
- A. 4-month-old client who is receiving scheduled vaccinations
- B. 3-year-old client who is afraid of needles
- C. 24-year-old client who is 6 weeks postpartum
- D. 32-year-old client who is pregnant at 12 weeks gestation
- E. 45-year-old client with a history of HIV
Correct Answer: B, C
Rationale: The live-attenuated vaccine is safe for healthy individuals aged 2-49, like the 3-year-old (B) and postpartum client (C). It's contraindicated for infants under 2 (A), pregnant women (D), and immunocompromised clients (E).
The client with COPD may lose weight despite having adequate caloric intake. When counseling the client in ways to maintain an optimal weight, the nurse should tell the client to:
- A. Continue the same caloric intake and decrease his activity level
- B. Increase his activity level to stimulate his appetite
- C. Increase the amount of complex carbohydrates and decrease the amount of fat intake
- D. Decrease the amount of complex carbohydrates while increasing calories, protein, fat, vitamins, and minerals
Correct Answer: D
Rationale: Clients with COPD often have increased metabolic demands and may lose weight. To maintain optimal weight, they should increase overall caloric intake, including protein, fat, vitamins, and minerals, while possibly decreasing complex carbohydrates to balance the diet. Answer A is incorrect as decreasing activity is not beneficial. Answer B may not be feasible due to respiratory limitations. Answer C does not address the need for increased calories and nutrients.
The spouse of a client with Alzheimer's disease expresses concern about the burden of caregiving. Which of the following actions by the nurse should be a priority?
- A. Link the caregiver with a support group
- B. Ask friends to visit regularly
- C. Schedule a home visit each week
- D. Request anti-anxiety prescriptions
Correct Answer: A
Rationale: Assisting caregivers to locate and join support groups is most helpful. Families share feelings and learn about services such as respite care. Health education is also available through local and national Alzheimer's chapters.