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Following discharge teaching, a male client with duodenal ulcer tells the nurse the
he will drink plenty of dairy products, such as milk, to help coat and protect his
ulcer. What is the best follow-up action by the nurse?
a. Remind the client that it is also important to switch to decaffeinated coffee and
tea.
b. Suggest that the client also plan to eat frequent small meals to reduce
discomfort
c. Review with the client the need to avoid foods that are rich in milk and cream.
d. Reinforce this teaching by asking the client to list a dairy food that he might
select.
Review with the client the need to avoid foods that are rich in milk and cream
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should
be avoided.
A male client with hypertension, who received new antihypertensive prescriptions
at his last visit returns to the clinic two weeks later to evaluate his blood pressure
(BP). His BP is 158/106 and he admits that he has not been taking the prescribed
medication because the drugs make him "feel bad". In explaining the need for
hypertension control, the nurse should stress that an elevated BP places the client
at risk for which pathophysiological condition?
a. Blindness secondary to cataracts
b. Acute kidney injury due to glomerular damage
c. Stroke secondary to hemorrhage
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d. Heart block due to myocardial damage
Stroke secondary to hemorrhage
Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
hypertension.
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly
admitted client who has a seizure disorder. The client is supine and the UAP is
placing soft pillows along the side rails. What action should the nurse implement?
a. Ensure that the UAP has placed the pillows effectively to protect the client.
b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows.
c. Assume responsibility for placing the pillows while the UAP completes another
task.
d. Ask the UAP to use some of the pillows to prop the client in a side lying
position.
Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows
Rationale: The nurse should instruct the UAP to pad the side rails with soft
blankest because the use of pillows could result in suffocation and would need to
be removed at the onset of the seizure. The nurse can delegate paddling the side
rails to the UAP
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An adolescent with major depressive disorder has been taking duloxetine
(Cymbalta) for the past 12 days. Which assessment finding requires immediate
follow-up
a. Describes life without purpose
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating.
Describes life without purpose
Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake
inhibitor that is known to increase the risk of suicidal thinking in adolescents and
young adults with major depressive disorder. B, C and D are side effects
A 60-year-old female client with a positive family history of ovarian cancer has
developed an abdominal mass and is being evaluated for possible ovarian cancer.
Her Papanicolau (Pap) smear results are negative. What information should the
nurse include in the client's teaching plan
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled out
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Following discharge teaching, a male client with duodenal ulcer tells the nurse the
he will drink plenty of dairy products, such as milk, to help coat and protect his
ulcer. What is the best follow-up action by the nurse?
a. Remind the client that it is also important to switch to decaffeinated coffee and
tea.
b. Suggest that the client also plan to eat frequent small meals to reduce
discomfort
c. Review with the client the need to avoid foods that are rich in milk and cream.
d. Reinforce this teaching by asking the client to list a dairy food that he might
select.
Review with the client the need to avoid foods that are rich in milk and cream
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should
be avoided.
A male client with hypertension, who received new antihypertensive prescriptions
at his last visit returns to the clinic two weeks later to evaluate his blood pressure
(BP). His BP is 158/106 and he admits that he has not been taking the prescribed
medication because the drugs make him "feel bad". In explaining the need for
hypertension control, the nurse should stress that an elevated BP places the client
at risk for which pathophysiological condition?
a. Blindness secondary to cataracts
b. Acute kidney injury due to glomerular damage
c. Stroke secondary to hemorrhage
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d. Heart block due to myocardial damage
Stroke secondary to hemorrhage
Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
hypertension.
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly
admitted client who has a seizure disorder. The client is supine and the UAP is
placing soft pillows along the side rails. What action should the nurse implement?
a. Ensure that the UAP has placed the pillows effectively to protect the client.
b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows.
c. Assume responsibility for placing the pillows while the UAP completes another
task.
d. Ask the UAP to use some of the pillows to prop the client in a side lying
position.
Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows
Rationale: The nurse should instruct the UAP to pad the side rails with soft
blankest because the use of pillows could result in suffocation and would need to
be removed at the onset of the seizure. The nurse can delegate paddling the side
rails to the UAP
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An adolescent with major depressive disorder has been taking duloxetine
(Cymbalta) for the past 12 days. Which assessment finding requires immediate
follow-up
a. Describes life without purpose
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating.
Describes life without purpose
Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake
inhibitor that is known to increase the risk of suicidal thinking in adolescents and
young adults with major depressive disorder. B, C and D are side effects
A 60-year-old female client with a positive family history of ovarian cancer has
developed an abdominal mass and is being evaluated for possible ovarian cancer.
Her Papanicolau (Pap) smear results are negative. What information should the
nurse include in the client's teaching plan
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled out
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