Nokea
Which of the following statements by the client indicate an understanding of the discharge teaching? Select all that apply.
- A. I will eat small, frequent meals.
- B. I should expect my bowel movements to be pale in color.
- C. I will limit my morning coffee to no more than two cups.
- D. I will notify my provider if my urine is dark.
- E. I will eat fish for dinner at least twice per week.
Correct Answer: A,D,E
Rationale: The correct statements (A, D, E) demonstrate an understanding of discharge teaching. A shows awareness of dietary recommendations post-discharge. D indicates knowledge of abnormal urine color as a reason to notify the provider. E reflects comprehension of incorporating fish in the diet for health benefits. The incorrect choices (B, C) suggest misconceptions. B is inaccurate as pale bowel movements may indicate a liver issue. C may be harmful as coffee can interfere with medication.
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Which of the following actions should the nurse take?
- A. Limit oral feedings to 30 min in length.
- B. Check the infant's oxygen saturation every 6 hr
- C. Place the infant in the prone position for naps
- D. Weigh the infant every other day.
Correct Answer: A
Rationale: Limiting feeding durations conserves energy for infants with heart failure.
Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require follow-up.
- A. Smoking marijuana to clear their mind
- B. Attends school regularly
- C. Heart rate 99/min
- D. Client experiences nightmares
- E. BP 122/80 mm Hg
- F. Caregiver reporting client acting differently than usual
- G. Witnessing their family's death
Correct Answer: A,D,F,G
Rationale: These findings suggest unresolved trauma and substance use, requiring intervention.
The client is at risk for developing-----due to---
- A. mania
- B. serotonin syndrome
- C. psychosis
- D. feelings of hopelessness
- E. adverse effects of paroxetine
- F. anxiety
Correct Answer: B,E
Rationale: Increasing paroxetine while discontinuing fluoxetine can lead to serotonin syndrome.
Which of the following actions should the nurse take first?
- A. Determine the client's Glasgow Coma Scale score
- B. Insert an indwelling urinary catheter for the client.
- C. Administer mannitol IV bolus to the client
- D. Prepare the client for an MRI of the brain.
Correct Answer: A
Rationale: The correct answer is A: Determine the client's Glasgow Coma Scale (GCS) score. This is the priority action as it helps assess the client's level of consciousness and neurological status quickly. It guides further interventions and treatment decisions. Inserting an indwelling urinary catheter (B) or administering mannitol IV bolus (C) may be needed but assessing neurological status comes first. Preparing for an MRI (D) is important but not the initial step.
A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care?(Select all that apply.)
- A. Give the client one simple direction at a time
- B. Refute the client's delusions using logic
- C. Allow the client to choose among a variety of activities each day
- D. Reinforce orientation to time, place, and person
- E. Establish eye contact when communicating with the client.
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
A: Giving the client one simple direction at a time is essential for someone with dementia to reduce confusion and facilitate understanding.
D: Reinforcing orientation to time, place, and person helps maintain the client's sense of reality and reduce disorientation.
E: Establishing eye contact when communicating with the client enhances connection and understanding, aiding in effective communication.
Incorrect Choices:
B: Refuting the client's delusions using logic may lead to frustration and agitation, as individuals with dementia may not be able to understand or accept logical arguments.
C: Allowing the client to choose among a variety of activities each day may overwhelm them with choices, leading to increased confusion and agitation.