A nurse in an outpatient clinic is caring for a client
Vital Signs
BP 124/68 mm Hg
Heart rate 80/min
Temperature 37° C (98.6° F) Respiratory rate 16/min Weight 67.1 kg (148 lb)
Which of the following statements should the nurse include in the client's teaching?
Select all that apply.
Try using an abdominal support belt
Take hot showers to help relieve itching"
"Wear loose-fitting clothing"
"Eat two large meals a day."
You should avoid fried foods"
Correct Answer : C,D,G
Choice A reason:
"Try using an abdominal support belt". This statement is incorrect. There is no indication or relevance for using an abdominal support belt based on the vital signs and weight provided. This statement is not appropriate for the client's teaching.
Choice B reason:
"Take hot showers to help relieve itching" This statement is incorrect. Itching is not mentioned in the vital signs and weight provided. Additionally, taking hot showers might not be relevant to the client's condition or needs. This statement is not appropriate for the client's teaching.
Choice C reason:
"Wear loose-fitting clothing" This is an appropriate statement for the client's teaching. Wearing loose-fitting clothing can provide comfort and allow better circulation, which might be helpful for some clients.
Choice D reason:
"Wear flat or low-heeled shoes" This is an appropriate statement for the client's teaching. Wearing flat or low-heeled shoes can help provide comfort and support, especially if the client has any foot or back issues.
Choice E reason:
"You can douche twice weekly." Douche is not relevant to the vital signs and weight provided, and it is generally not recommended for routine use as it can disrupt the natural balance of vaginal flora. This statement is not appropriate for the client's teaching.
Choice F reason:
"Eat two large meals a day." This statement does not align with a healthy eating pattern, and it might not be appropriate for the client's health needs. The recommendation for a balanced diet usually includes several smaller meals throughout the day. This statement is not appropriate for the client's teaching.
Choice G reason:
"You should avoid fried foods." This is an appropriate statement for the client's teaching. Avoiding fried foods can be beneficial for overall health, especially if the client is trying to manage weight or maintain a balanced diet.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Encouraging clients to establish a timeline for grieving might not be appropriate or helpful, as grief processes are individual and non-linear.
B. Correct. Coping with changes in family dynamics is a relevant topic for a support group of this nature, as suicide often brings significant family changes.
C. Incorrect. Focusing on preventing suicide is not the primary goal of this support group; coping and healing are more appropriate.
D. Incorrect. Allowing clients to share negative aspects of their relationship can promote emotional healing and understanding, which is essential in this context.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should instruct the parents to report sudden, persistent headaches in a child with sickle cell anemia because it could be a sign of a cerebrovascular accident (stroke) Sickle cell anemia predisposes individuals to vaso-occlusive crises, which can lead to stroke due to impaired blood flow. Early detection and intervention are crucial in preventing complications.
Choice B rationale:
Applying cold compresses to painful areas may help in managing pain during vaso-occlusive crises, but it is not as critical as identifying signs of more severe complications such as stroke. This instruction does not address the urgency of reporting sudden, persistent headaches.
Choice C rationale:
Restricting fluid intake during times of stress is not appropriate for a child with sickle cell anemia. In fact, maintaining adequate hydration is important to prevent vaso-occlusive crises. Dehydration can exacerbate sickling of red blood cells, leading to more pain and complications.
Choice D rationale:
Avoiding meningococcal immunizations is not appropriate for a child with sickle cell anemia. In fact, children with sickle cell disease are at an increased risk of infections, including meningitis. Immunizations, including those for meningococcus, are essential to prevent life-threatening infections in these individuals.
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