Nokea
Which of the following actions should the nurse instruct the client to complete FIRST to establish a normal urinary pattern?
- A. Urinate every two hours.
- B. Record each time you urinate.
- C. Keep a record of your daily fluid intake.
- D. Stay near a bathroom.
Correct Answer: C
Rationale: Tracking fluid intake first helps correlate intake with urinary output, guiding interventions like scheduled voiding. Options A, B, and D are subsequent steps or supportive measures.
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The nurse is teaching the client with an ileal conduit regarding skin care to prevent excoriation. In addition to applying a well-fitted collection bag the client should be told to empty the collection bag:
- A. Every hour
- B. When it is half full
- C. Once daily
- D. When it is one-third full
Correct Answer: D
Rationale: The client should be told to empty the collection bag when it is one-third full. Answer A isn't necessary or feasible, so it is incorrect. Waiting until the collection bag is half full or more as suggested in answers B and C increases the likelihood of skin exposure to urine thereby contributing to excoriation.
A two year-old child is brought to the provider's office with a chief complaint of mild diarrhea for two days. Nutritional counseling by the nurse should include which statement?
- A. Place the child on clear liquids and gelatin for 24 hours
- B. Continue with the regular diet and include oral rehydration fluids
- C. Give bananas, apples, rice and toast as tolerated
- D. Place NPO for 24 hours, then rehydrate with milk and water
Correct Answer: B
Rationale: Current recommendations for mild to moderate diarrhea are to maintain a normal diet with fluids to rehydrate.
A woman who recently had a simple mastectomy is about to be discharged. She seems very concerned about such things as where to find the best prosthesis, suitable underwear, and swimsuits, and adjusting to life with only one breast. Which resource is appropriate for the nurse to recommend?
- A. A psychologist or psychiatrist
- B. Reach to Recovery
- C. Pastoral counseling
- D. Her physician
Correct Answer: B
Rationale: Reach to Recovery offers peer support and resources for mastectomy patients, addressing prosthesis and lifestyle adjustments. Other options are less specific.
A postoperative client has returned to his room from the surgical recovery area. The client is sleeping, and the nurse notes that the client is disoriented when aroused.
Which of the following actions, if taken by the nurse, is BEST?
- A. Place the call bell within the client's reach.
- B. Stay with the client until he is totally oriented.
- C. Restrain all four extremities until the client is oriented.
- D. Elevate the side rails until the client is fully awake.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not the safety action (2) unnecessary to stay with the client, especially while he is sleeping (3) restraints are unnecessary at this time (4) correct-side rails should always be elevated for any disoriented client
A male client's behavior begins to escalate into aggressive behavior.
The nurse is caring for clients on the psychiatric unit. Suddenly, a male client's behavior begins to escalate into aggressive behavior. It would be MOST important for the nurse to take which of the following actions?
- A. Utilize an organized team to place the client in seclusion.
- B. Leave the client alone in his room to identify feelings of anger.
- C. Redirect the client to a quiet activity to divert his attention and not disturb the other clients.
- D. Assist the client to identify and express his feelings of increasing anxiety, frustration, and anger.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) nurse can be helpful in using psychological/communication strategies before utilizing seclusion (2) leaving the client alone can become potentially dangerous to the client and the property (3) encouraging the client to become involved in a quiet activity might further escalate his frustration and anger because the ability to focus and concentrate is diminished due to an elevated anxiety level (4) correct-as client's anger begins to escalate, nurse can be helpful in using psychological/communication strategies before utilizing seclusion