Nokea
A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections.
Which of the following interventions should the nurse include in the teaching?
- A. Drink 2 liters of warm water per day.
- B. Wipe from back to front after urination.
- C. Urinate immediately after sexual intercourse.
- D. Limit fluid intake to prevent frequent urination.
Correct Answer: C
Rationale: The correct answer is C: Urinate immediately after sexual intercourse. This intervention helps prevent urinary tract infections by flushing out bacteria that may have entered the urethra during intercourse. It is important to teach this to promote urinary tract health.
A: Drinking 2 liters of warm water per day is generally good for hydration but not directly related to preventing UTIs.
B: Wiping from back to front can actually introduce bacteria from the rectal area to the urethra, increasing the risk of UTIs.
D: Limiting fluid intake to prevent frequent urination is not recommended as it can lead to dehydration and concentration of urine, potentially worsening UTIs.
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A nurse is assessing a 5-year-old child who has diabetes insipidus and is receiving desmopressin.
Which finding should the nurse identify as an indication that the medication is effective?
- A. Heart rate 140/min
- B. Capillary refill 3 seconds
- C. Cessation of nocturnal enuresis
- D. Absence of hypoglycemic episodes
Correct Answer: C
Rationale: The correct answer is C: Cessation of nocturnal enuresis. This indicates the medication is effective because it shows improvement in the condition being treated, which in this case is nocturnal enuresis. Nocturnal enuresis is the involuntary passage of urine during sleep and it can be a result of various factors such as hormonal imbalance or bladder control issues. Therefore, if the medication is effective, it should lead to the cessation of this symptom.
Heart rate (A) and capillary refill (B) are not necessarily indicators of the effectiveness of the medication in treating nocturnal enuresis. Absence of hypoglycemic episodes (D) is more related to diabetes management rather than nocturnal enuresis.
A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who has diabetes mellitus.
Which of the following action should the nurse take?
- A. Determine if the AP has the skills to perform the test.
- B. Help the AP performed the blood glucose test
- C. Assign the AP to ask the client is taking his diabetic medication today
- D. Have AP check the medical record for prior blood glucose test results
Correct Answer: A
Rationale: The correct answer is A because the nurse should first assess if the AP has the necessary skills to perform the blood glucose test. This step is crucial to ensure patient safety and accurate test results. Helping the AP perform the test (B) without assessing their skills can lead to errors. Assigning the AP to ask about medication (C) is not directly related to the task at hand. Having the AP check records (D) is important but should come after confirming their skills. The other choices are not relevant to the immediate situation.
A nurse is assessing a client who has historic personality disorder. Which of the following manifestations should the nurse expect?
- A. Suspicious of others
- B. Callousness
- C. self-centered behavior
- D. violates others rights
Correct Answer: C
Rationale: The correct answer is C: self-centered behavior. Individuals with historic personality disorder often display self-centered behavior as they prioritize their own needs and desires above others. This is due to their excessive need for admiration and attention. The other options are incorrect because: A: Suspicious of others is more characteristic of paranoid personality disorder. B: Callousness is more indicative of antisocial personality disorder. D: Violates others' rights is a feature of antisocial personality disorder as well.
The nurse is caring for a client who is on bed rest.
The nurse should recognize that which of the following findings is a complication of immobility
- A. Increased BP
- B. Urinary frequency
- C. Swollen area on calf
Correct Answer: C
Rationale: The correct answer is C: Swollen area on calf. Immobility can lead to blood pooling in the lower extremities, causing swelling, pain, and potentially leading to deep vein thrombosis (DVT). This is a serious complication that can result from prolonged periods of immobility. Increased blood pressure (choice A) is not typically a direct complication of immobility. Urinary frequency (choice B) is more commonly associated with conditions like urinary tract infections or overactive bladder, not immobility. Swollen area on the calf (choice C) is a hallmark sign of potential DVT in immobile patients.
A nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver states, Providing constant care is very stressful and is affecting all areas of my life.
Which of the following actions should the nurse take?
- A. Assist the caregiver to arrange a daycare program for the client.
- B. Advise the caregiver to take time for themselves when possible.
- C. Encourage the caregiver to focus on the positive aspects of caregiving.
- D. Remind the caregiver that their loved one depends on them completely.
Correct Answer: A
Rationale: The correct answer is A because arranging a daycare program for the client allows the caregiver to have a break and attend to their own needs. This promotes self-care, prevents burnout, and ensures the well-being of both the caregiver and the client. Choice B, advising the caregiver to take time for themselves, is not as effective as it doesn't provide a concrete solution like arranging daycare. Choice C, encouraging the caregiver to focus on the positive aspects, may be helpful but does not address the need for respite. Choice D, reminding the caregiver of their loved one depending on them, may increase guilt and stress.