Nokea
Which of the ff is a nursing intervention to ensure that the client is free from injury caused by falls?
- A. Nurse monitors for chest pain and elevated low-density lipoprotein levels
- B. Nurse monitors for swelling and heaviness of legs
- C. Nurse monitors postural changes in BP
- D. Nurse monitors temperature for mild fever
Correct Answer: B
Rationale: Monitoring for swelling and heaviness of legs is a nursing intervention that can help prevent falls. Swelling and heaviness of legs could indicate conditions such as edema or circulation problems, which may increase the risk of falls due to impaired mobility and stability. By identifying these signs early on, the nurse can intervene promptly to address the underlying issues and prevent potential falls. This proactive approach aligns with the goal of ensuring the client is free from injury caused by falls. Monitoring for chest pain and elevated low-density lipoprotein levels, postural changes in BP, or mild fever may be important for overall client care but are not directly related to fall prevention.
You may also like to solve these questions
A child newly diagnosed with diabetes mellitus has been stabilized with insulin injections daily. A nurse prepares discharge teaching plan regarding the insulin. The teaching plan should reinforce which of the following concepts?
- A. Always keep insulin vials refrigerated
- B. Increase the amount of insulin before exercise
- C. Ketones in the urine signify a need for less insulin
- D. Systematically rotate injection sites
Correct Answer: D
Rationale: The correct concept that should be reinforced in the teaching plan is to systematically rotate injection sites. Rotating injection sites helps prevent lipodystrophy - changes in fat tissue due to repeated injections in the same spot. This can ensure that the insulin is properly absorbed and prevent complications. It is important for the child and their family to understand the importance of rotating injection sites to maintain good insulin absorption and reduce the risk of complications.
Although most relapses in children with Wilms tumor occur early (within 2 yr of diagnosis) and have a favorable outcome, about 15% suffer relapse. Relapse includes all the following EXCEPT
- A. low stage (I/II) at diagnosis
- B. no prior radiotherapy
- C. anaplastic histology
- D. more than 12 mo from nephrectomy
Correct Answer: C
Rationale: Anaplastic histology is associated with a poorer prognosis and is not typically associated with favorable relapse outcomes.
During the initial assessment, he is placed in a modified Trendelenburg position. What desired effect should the position have on the client?
- A. An increase in the client's blood pressure
- B. An increase in the client's respiratory rate f. An increase in the client's heart rate h. A decrease in blood loss
- C. An increase in the client's respiratory rate
- D. An increase in the client's heart rate h. A decrease in blood loss
Correct Answer: A
Rationale: Placing a client in a modified Trendelenburg position involves having the client lie flat on the back with the legs elevated above the level of the heart. The main purpose of this position is to help increase blood pressure in cases of hypotension or shock. By raising the legs above the heart level, gravity helps to facilitate the return of venous blood to the heart, which can increase cardiac output and, consequently, blood pressure. This position is commonly used in clinical settings to help improve perfusion to vital organs and assist in stabilizing a client's blood pressure.
To meet the emotional needs of a 10-year-old patient who is dying, the most appropriate nursing action is to:
- A. answer questions honestly and frankly.
- B. avoid interruptions by coordinating nursing actions.
- C. encourage the patient to write in a journal.
- D. provide opportunities for the patient to interact with children of the same age.
Correct Answer: A
Rationale: Answering questions honestly and frankly helps build trust and provides clarity for the child during this difficult time.
As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?
- A. I know the hallucinations are parts of the disease
- B. I told her she is wrong and I explained to her what is right
- C. I help her do some tasks he cannot do for himself
- D. Ill turn off the TV when we go to another room
Correct Answer: B
Rationale: Option B, "I told her she is wrong and I explained to her what is right," would require the nurse to give further teaching because it indicates a lack of understanding about how to communicate with a person experiencing hallucinations. People with hallucinations may have a distorted sense of reality, and arguing with them or insisting on what is "right" can be counterproductive. The daughter would benefit from additional education on how to effectively communicate and support her father during episodes of hallucinations.