A nurse is planning care for a client who has leukemia and is prescribed bed rest. Which of the following interventions should the nurse include in the plan?
Have the client perform pulmonary hygiene every 8 hr.
Place the client on airborne precautions.
Turn the client every 4 hr and apply powder to moist areas.
Assess the client's urine for odor and cloudiness.
The Correct Answer is D
- Rationale for Choice A: Pulmonary hygiene is important for preventing pneumonia, especially in bedridden clients. However, it is not specific to the care of a client with leukemia unless they have a respiratory complication which necessitates such an intervention.
- Rationale for Choice B: Airborne precautions are typically used for clients who have infections that can be transmitted through the air, such as tuberculosis. Leukemia does not require airborne precautions unless the client has a coexisting airborne infection.
- Rationale for Choice C: Regular turning of the client can help prevent pressure ulcers and is a good practice for any bedridden patient. However, the use of powder is controversial as it can cake and lead to skin breakdown, and is not specifically indicated for leukemia care.
- Rationale for Choice D: Assessing the client's urine for odor and cloudiness is an important part of care for clients with leukemia. They are at increased risk for urinary tract infections due to immunosuppression, and changes in urine can indicate an infection that needs prompt treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Holding the fork through the entire meal can lead to mindless eating and overeating. The client should put down the fork between bites and chew slowly to savor the food and feel full faster.
Choice B rationale:
Planning meals day by day can be stressful and impractical for the client. The client might not have enough time or resources to prepare healthy meals every day, or might be tempted by unhealthy options when hungry. The client should plan meals ahead of time, such as weekly or monthly, and stock up on nutritious foods that are easy to prepare.
Choice C rationale:
Scheduling three times to eat each day can be too rigid and unrealistic for the client. The client might not feel hungry at the scheduled times, or might feel hungry in between meals and snack
on junk food. The client should listen to their body and eat when they are hungry, but not too hungry. The client should also eat slowly and stop when they are full, but not too full.
Choice D rationale:
Eating off a smaller plate can help reduce the portion size and calorie intake of the client. This is a simple and effective way to manage obesity without feeling deprived or hungry. A smaller plate can also create an illusion of having more food, which can increase the satisfaction of the meal.
Correct Answer is C
Explanation
Choice A rationale:
Survivors of sexual assault can exhibit a wide range of psychological symptoms, and their experiences may vary significantly. There is no universal pattern of symptoms that applies to all survivors.
Choice B rationale:
Psychotherapy, such as trauma-focused cognitive-behavioral therapy, has been shown to be effective in helping survivors of sexual assault cope with and heal from their experiences.
Choice C rationale:
Rationale:
It is important to emphasize that sexual assault survivors often know the perpetrator, as this information dispels the myth that most assaults are committed by strangers.
Education should provide accurate and evidence-based information to address misconceptions.
Choice D rationale:
Survivors of sexual assault come from diverse backgrounds and living situations, and their marital status or residence in metropolitan areas is not universally applicable.
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