A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching?

"I can drink vegetable juice with a meal."

"I can season my foods with garlic and onion salts."

"I can have a frozen fruit juice bar for dessert."

"I can have mayonnaise on my sandwiches."

Answer and Explanation

The Correct Answer is C

A frozen fruit juice bar for dessert is a low-sodium option that can satisfy the client's sweet tooth. According to the National Health and Nutrition Examination Survey, Americans consume about 3700 mg of sodium daily, which is much higher than the recommended 2300 mg for the general population and 1500 mg for those with heart failure. Excessive sodium intake can lead to fluid retention, hypertension, and worsening of heart failure symptoms. Therefore, the client should avoid high-sodium foods such as vegetable juice, garlic and onion salts, and mayonnaise.

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Correct Answer is C

Explanation

Altered level of consciousness (LOC) is the earliest and most sensitive indicator of increased ICP, which can result from brain injury, tumor, hemorrhage, infection, or edema.

The nurse should monitor the client's LOC using the Glasgow Coma Scale (GCS) and report any changes or deterioration to the provider. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs of increased ICP that indicate brainstem compression and herniation, which are life-threatening emergencies.

A. May operate a motor vehicle when no longer taking analgesics. B. May place a small pillow under the head when sleeping. C. Increase intake of fiber-rich foods. D. Take tub baths instead of showers.

Correct Answer is A

Explanation

A halo device is a type of external fixation device that immobilizes the cervical spine after an injury or surgery. The device consists of a metal ring attached to four metal rods that are secured to a vest worn by the client. The device limits the movement of the head and neck, which can impair the client's ability to drive safely. The nurse should clarify with the provider if the client can operate a motor vehicle while wearing the halo device, as this may pose a risk for injury to the client and others on the road.

Placing a small pillow under the head when sleeping, increasing intake of fiber-rich foods, and taking tub baths instead of showers are all appropriate instructions for a client with a halo device

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A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching?

Nursing Test Bank

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