Nokea
Which of the following is most important discharge teaching for Mr. Dela Isla
- A. Emergency Numbers
- B. Relaxation technique
- C. Drug Compliance
- D. Dietary prescription SITUATION: Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
Correct Answer: C
Rationale: The correct answer is C: Drug Compliance. After a CVA (stroke), it is crucial for Mr. Dela Isla to understand and adhere to his prescribed medications. Medications help prevent further strokes and manage underlying conditions. Drug compliance ensures optimal treatment outcomes. Emergency Numbers (A) are important but not the priority post-stroke. Relaxation techniques (B) may be helpful but not as critical as medication adherence. Dietary prescription (D) is important but not as urgent as drug compliance in this scenario.
You may also like to solve these questions
Which client statement would indicate to the nurse that the client with polycythemia vera is in need further of instruction?
- A. I’ll be flying overseas to see my son and grandchildren for the holidays
- B. I plan to do my leg exercises at least three times a week
- C. I’m going to be walking in the mall everyday to build up my strength
- D. At night when I sleep, I like to use two pillows to raise my head up CARING FOR CLIENTS FOR DISORDERS OF THE LYMPHATIC SYSTEM
Correct Answer: D
Rationale: The correct answer is D because using two pillows to raise the head can increase the risk of venous stasis and thrombosis in a client with polycythemia vera. This condition involves an increased production of red blood cells, leading to thicker blood and potential clot formation. Elevating the head too much can impede blood flow, exacerbating the risk of clotting. Choices A, B, and C are all appropriate statements indicating good self-care practices and physical activity, which are beneficial for clients with polycythemia vera to improve circulation and overall health.
The patient is being discharged on furosemide (Lasix). The nurse evaluates the patient as understanding her medication teaching if she states that she will have which of the ff. laboratory tests monitored as ordered?
- A. “I will have my urine sodium checked.”
- B. “I will have my prothrombin time checked.”
- C. “I will have my calcium level checked.”
- D. “I will have my potassium level checked.”
Correct Answer: D
Rationale: The correct answer is D: "I will have my potassium level checked." Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias.
A: Monitoring urine sodium is not typically necessary for furosemide therapy.
B: Prothrombin time monitoring is unrelated to furosemide therapy.
C: Monitoring calcium levels is not directly affected by furosemide use.
In summary, monitoring potassium levels is essential due to the potential for hypokalemia with furosemide, while the other options are not directly relevant to this medication.
A client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:
- A. E-rosette immunofluorescence
- B. Enzyme-linked immunosorbent assay
- C. Quantification of T-lymphocytes (ELISA)
- D. Western blot test with ELISA
Correct Answer: D
Rationale: The correct answer is D, the Western blot test with ELISA. First, ELISA is used as a screening test for HIV antibodies. If positive, a confirmatory test like Western blot is needed to detect specific antibodies. Western blot is highly specific and confirms the presence of HIV antibodies. E-rosette immunofluorescence is not typically used for HIV diagnosis. Quantification of T-lymphocytes is used to monitor disease progression in HIV but does not confirm HIV infection. ELISA alone is not confirmatory; it needs to be followed by a more specific test like Western blot.
The nurse has entered a client’s room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference?
- A. Measure the client’s oral temperature.
- B. Ask a colleague for assistance.
- C. Give the client a clean gown and warm blankets.
- D. Obtain an order for blood cultures.
Correct Answer: A
Rationale: The correct answer is A: Measure the client’s oral temperature. This is the best follow-up because it directly assesses the client's body temperature, providing objective data to confirm the presence of fever. It is essential to gather accurate information to guide appropriate interventions. Asking a colleague for assistance (B) may not address the immediate need for temperature assessment. Giving the client a clean gown and warm blankets (C) may provide comfort but does not address the need for temperature measurement. Obtaining an order for blood cultures (D) is not the initial priority when the client is showing signs of fever; temperature measurement is the first step in assessing the client's condition.
The nurse is developing a plan of care for marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable?
- A. 24 hours
- B. 7 to 14 days
- C. 2 to 4 days
- D. 21 to 28 days
Correct Answer: B
Rationale: The correct answer is B: 7 to 14 days. Marrow suppression from floxuridine typically occurs 1-2 weeks after administration due to its effects on rapidly dividing cells in the bone marrow. This is known as the nadir period. Choices A, C, and D are incorrect because 24 hours is too soon for noticeable effects, 2 to 4 days is too short for the nadir period, and 21 to 28 days is too long for the onset of marrow suppression. The correct choice aligns with the expected timeframe for floxuridine's impact on bone marrow function.