A nurse is creating home instructions for a client who has immunodeficiency. Which of the following statements by the client indicates an understanding of the teaching?

I might experience harmless white patches in my mouth.

I will expect to have a mild, occasional fever.

I will avoid people who have just received a live vaccine.

I will limit the use of skin cream to once a week.

Answer and Explanation

The Correct Answer is C

Choice A reason:

The statement “I might experience harmless white patches in my mouth” could indicate the presence of oral thrush, a common fungal infection in immunocompromised individuals. However, this statement does not directly reflect an understanding of preventive measures or home care instructions for someone with immunodeficiency.

Choice B reason:

Expecting to have a mild, occasional fever is not a typical understanding of immunodeficiency care. While fevers can occur, they should not be considered normal or expected. Any fever in an immunocompromised person should be promptly evaluated by a healthcare provider as it could indicate an infection.

Choice C reason:

Avoiding people who have just received a live vaccine is a crucial preventive measure for individuals with immunodeficiency. Live vaccines contain a weakened form of the virus or bacteria, which can pose a risk to immunocompromised individuals. This statement shows an understanding of the need to avoid potential sources of infection.

Choice D reason:

Limiting the use of skin cream to once a week is not a standard recommendation for immunodeficiency care. Skin care is important, but the frequency of using skin cream should be based on individual needs and the type of cream used. This statement does not reflect a specific understanding of immunodeficiency management.

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Correct Answer is D

Explanation

Choice A reason:

Walking in front of the client to guide her in moving the walker is not recommended. The nurse should walk beside or slightly behind the client to provide support and ensure safety. Walking in front can obstruct the nurse’s view of the client’s movements and make it difficult to assist if the client loses balance.

Choice B reason:

Ensuring that the upper bar of the walker is level with the client’s waist is incorrect. The correct height for the walker is when the client’s elbows are slightly bent (about 15-30 degrees) when holding the handgrips. This allows for better control and reduces the risk of falls.

Choice C reason:

Having the client move one leg forward with the walker is not the correct technique. The client should first lift the walker and place it a short distance ahead, then step forward with the weaker leg first, followed by the stronger leg. This method provides better stability and support.

Choice D reason:

Checking that the client lifts the walker and then places it down in front of her is the correct action. This ensures that the walker is used properly, providing maximum support and reducing the risk of tripping or falling. The client should lift the walker, move it forward, and then step into the walker area.

A. Restrict head movement. B. Remove eye patch in one month. C. Apply cool compresses. D. Eye drops to constrict the pupils will be prescribed.

Correct Answer is A

Explanation

Choice A reason:

Restricting head movement is a crucial preoperative instruction for a client scheduled for retinal detachment surgery. This helps to prevent further detachment and ensures that the retina remains in the best possible position for surgery. Keeping the head still minimizes the risk of additional damage and helps maintain the current state of the retina.

Choice B reason:

Removing an eye patch in one month is not a standard preoperative instruction. Eye patches are typically used postoperatively to protect the eye and aid in healing. The duration for wearing an eye patch varies depending on the specific case and the surgeon’s recommendations.

Choice C reason:

Applying cool compresses is not a typical preoperative instruction for retinal detachment surgery. Cool compresses are generally used to reduce swelling and discomfort postoperatively. Preoperative care focuses more on stabilizing the condition and preparing the client for surgery.

Choice D reason:

Eye drops to constrict the pupils are not commonly prescribed preoperatively for retinal detachment surgery. Instead, eye drops to dilate the pupils are often used to allow the surgeon a better view of the retina during the procedure. Pupil constriction is not typically necessary before surgery.

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A nurse is creating home instructions for a client who has immunodeficiency. Which of the following statements by the client indicates an understanding of the teaching?

Nursing Test Bank

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Correct Answer is D

Explanation

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