A nurse is caring for a client who has just been diagnosed with cancer of the colon. The client asks the nurse about what the provider might be planning to do. Which of the following nursing responses should the nurse make?

Provide the client with articles from the internet that explain colon cancer stages.

Encourage the client to write down questions to ask the provider.

Explain the various options available for treatment based on the cancer stage.

Assure the client that the provider will explain what has been planned.

Answer and Explanation

The Correct Answer is B

Choice A reason: Providing the client with articles from the internet that explain colon cancer stages is not the best approach. While it is important for the client to understand their condition, the nurse should ensure that the information is accurate and tailored to the client’s specific situation. Additionally, the nurse should facilitate a direct conversation between the client and the healthcare provider to address any questions or concerns.

Choice B reason: Encouraging the client to write down questions to ask the provider is an excellent approach. This empowers the client to actively participate in their care and ensures that they have a clear understanding of their diagnosis and treatment options. It also helps the client to remember important questions during their consultation with the provider.

Choice C reason: Explaining the various options available for treatment based on the cancer stage is not within the nurse’s scope of practice. Detailed discussions about treatment options should be conducted by the healthcare provider, who has the expertise to provide accurate and comprehensive information tailored to the client’s specific medical condition.

Choice D reason: Assuring the client that the provider will explain what has been planned is a supportive response, but it does not actively engage the client in their care. While it is important to reassure the client, the nurse should also encourage the client to prepare questions and participate in discussions with the provider to ensure they fully understand their treatment plan.

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Correct Answer is ["A","B","D"]

Explanation

Choice A: Time the duration of the seizure

Reason: Timing the duration of a seizure is crucial for several reasons. Firstly, it helps in determining the type of seizure and its severity. Seizures lasting more than 5 minutes are considered medical emergencies and may require immediate intervention to prevent complications such as status epilepticus, which is a prolonged seizure that can cause brain damage or death. By recording the start and end times, healthcare providers can assess the effectiveness of treatments and make necessary adjustments. Additionally, this information is vital for documenting the patient’s medical history and for future reference in managing the condition.

Choice B: Administer supplemental oxygen to the client

Reason: Administering supplemental oxygen is essential during a seizure, especially when the client’s oxygen saturation levels drop below the normal range of 95-100%. In the provided scenario, the client’s oxygen saturation is 86%, which is significantly low and indicates hypoxemia. Hypoxemia can lead to further complications, including brain damage due to insufficient oxygen supply. Providing supplemental oxygen helps maintain adequate oxygen levels in the blood, ensuring that vital organs, including the brain, receive enough oxygen to function properly. This intervention is critical in preventing hypoxic injuries and promoting recovery post-seizure.

Choice C: Place a tongue depressor in the client’s mouth

Reason: Placing a tongue depressor in the client’s mouth during a seizure is not recommended and can be dangerous. This outdated practice was once believed to prevent the client from biting their tongue, but it poses significant risks. The client could bite down on the depressor, causing dental injuries or even breaking the depressor, leading to choking hazards. Modern seizure management guidelines advise against placing any objects in the mouth during a seizure. Instead, the focus should be on ensuring the client’s safety by clearing the area of any harmful objects and positioning them safely.

Choice D: Turn the client to the side

Reason: Turning the client to the side, also known as the recovery position, is a critical intervention during a seizure. This position helps maintain an open airway and reduces the risk of aspiration, which can occur if the client vomits or has excessive saliva. Aspiration can lead to serious respiratory complications, including pneumonia. By positioning the client on their side, gravity helps drain fluids from the mouth, preventing them from entering the airway9. This simple yet effective measure is a standard practice in seizure management to ensure the client’s safety and comfort.

Choice E: Restrain the client

Reason: Restraining a client during a seizure is not recommended and can be harmful. Seizures involve involuntary muscle contractions, and attempting to restrain the client can lead to injuries such as fractures, muscle tears, or dislocations. Additionally, restraint can increase the client’s agitation and stress, potentially worsening the seizure. The appropriate approach is to ensure the client’s safety by removing nearby objects that could cause injury and allowing the seizure to run its course. Gentle guidance and support should be provided without applying force.

A. Low-protein, low-potassium diet B. Regular diet, no added salt C. Low-carbohydrate, low-protein diet D. Low-sodium, fluid-restricted diet

Correct Answer is D

Explanation

Choice A reason: Low-protein, low-potassium diet

A low-protein, low-potassium diet is not typically recommended for acute glomerulonephritis. While protein intake may need to be moderated to reduce the workload on the kidneys, potassium restriction is usually not necessary unless there is hyperkalemia (high potassium levels) present. The primary dietary focus should be on managing fluid and sodium intake to control edema and hypertension.

Choice B reason: Regular diet, no added salt

A regular diet with no added salt is a step in the right direction but may not be sufficient for managing acute glomerulonephritis with significant edema. Sodium restriction is crucial to help reduce fluid retention and control blood pressure. Therefore, a more stringent low-sodium diet is often necessary.

Choice C reason: Low-carbohydrate, low-protein diet

A low-carbohydrate, low-protein diet is not appropriate for managing acute glomerulonephritis. Carbohydrate intake does not directly impact kidney function in this context, and protein intake should be moderated rather than severely restricted. The focus should be on sodium and fluid management.

Choice D reason: Low-sodium, fluid-restricted diet

A low-sodium, fluid-restricted diet is the most appropriate choice for a client with acute glomerulonephritis and peripheral edema. Reducing sodium intake helps to minimize fluid retention and control blood pressure, while fluid restriction helps to prevent further edema and manage the workload on the kidneys. This dietary approach is essential for managing the symptoms and complications associated with acute glomerulonephritis.

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A nurse is caring for a client who has just been diagnosed with cancer of the colon. The client asks the nurse about what the provider might be planning to do. Which of the following nursing responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a seizure disorder. Exhibits A nurse is caring for a client who has a seizure disorder. What following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is caring for a school-age child who has acute glomerulonephritis with peripheral edema and is producing 35 mL of urine per hour. The nurse should place the client on which of the following diets?

Correct Answer is D

Explanation

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