Which of the following should the nurse include in the disch...

Which of the following should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation?

A. Carefully test the temperature of bath water.
B. Avoid kitchen activities because of the risk of injury.
C. Avoid hot water bottles and heating pads.
D. Inspect the skin daily for injury or pressure points.
E. Wear warm clothing when outside in cold temperatures.

Correct Answer: A,C,D,E

Rationale: Testing bath water temperature (A), avoiding hot water bottles/heating pads (C), daily skin inspection (D), and wearing warm clothing (E) prevent injury due to impaired sensation. Avoiding kitchen activities entirely is overly restrictive.

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The physician has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube:

A. For administration of oxygen.
B. To promote formation of lung scar tissue.
C. To insert antibiotics into the pleural space.
D. To remove air and fluid.

Correct Answer: D

Rationale: A chest tube in pneumothorax removes air and fluid from the pleural space, restoring lung expansion. It is not used for oxygen, scar tissue, or antibiotics.

A client has been diagnosed with adenocarcinoma of the stomach and is scheduled to undergo a subtotal gastrectomy (Billroth II procedure). During preoperative teaching, the nurse is reinforcing information about the surgical procedure. Which of the following explanations is most accurate?

A. The procedure will result in enlargement of the pyloric sphincter.
B. The procedure will result in anastomosis of the gastric stump to the jejunum.
C. The procedure will result in removal of the duodenum.
D. The procedure will result in repositioning of the vagus nerve.

Correct Answer: B

Rationale: The Billroth II procedure involves anastomosis of the gastric stump to the jejunum, bypassing the duodenum. The other options are incorrect descriptions of the procedure.

What should the nurse assess in a client receiving anticonvulsant therapy?

A. Liver function.
B. Blood pressure.
C. Pain levels.
D. Skin integrity.

Correct Answer: A

Rationale: Liver function is assessed due to the potential hepatotoxicity of anticonvulsant medications.

A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client:

A. Adds dried fruit to cereal and baked goods.
B. Cooks tomato-based foods in iron pots.
C. Drinks coffee or tea with meals.
D. Adds vitamin C to all meals.

Correct Answer: C

Rationale: Drinking coffee or tea with meals inhibits iron absorption due to tannins, which bind to iron and reduce its bioavailability. This indicates a lack of understanding of nutritional counseling for anemia, as the client should avoid these beverages during meals. Adding dried fruit (iron source), cooking in iron pots (increases iron content), and consuming vitamin C (enhances iron absorption) are appropriate strategies.

The nurse has been assigned to a client who is hearing impaired and reads speech. Which of the following strategies should the nurse incorporate when communicating with the client? Select all that apply.

A. Avoiding being silhouetted against strong light.
B. Not blocking out the person's view of the speaker's mouth.
C. Facing the client when talking.
D. Having bright light behind so the individual can see.
E. Ensuring the client is familiar with the subject material before discussing.
F. Talking to the client while doing other nursing procedures.

Correct Answer: A,B,C

Rationale: To facilitate lip-reading, the nurse should avoid strong backlighting, not block the view of the mouth, and face the client directly to ensure clear visibility of facial expressions and lips.