Client Statement
The nurse returns in 1 week for a follow-up appointment. For each client statement, indicate if the client understood the teaching or needs further teaching.
I purchased a large magnifying glass.
I’m adding bananas to my oatmeal every morning.
Instead of being barefoot, I wear socks.
I moved my medicine bottles into the living room.
I switched to eating apples and oranges for a nighttime snack.
I placed a lamp on my bedside table.
I prepared a large batch of beans, so I have a fast meal every night.
I added a nonslip throw rug at my kitchen sink.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"},"H":{"answers":"B"}}
Choice A Reason:
The client states, “I purchased a large magnifying glass.” While this shows an attempt to address the issue of blurred vision, it does not fully address the safety concerns related to macular degeneration. The client should be encouraged to use additional visual aids, such as better lighting and possibly electronic magnifiers, to ensure they can see clearly and avoid accidents. Therefore, this statement indicates that the client needs further teaching.
Choice B Reason:
The client states, “I’m adding bananas to my oatmeal every morning.” This is a positive dietary change. Bananas are rich in potassium, which can help manage blood pressure, a crucial aspect for someone with hypertension. Additionally, adding fruit to breakfast can improve overall nutrition. Therefore, this statement indicates that the client understood the teaching.
Choice C Reason:
The client states, “Instead of being barefoot, I wear socks.” While wearing socks is better than being barefoot, it is not the safest option. Socks can still be slippery on certain surfaces, increasing the risk of falls. The client should be encouraged to wear non-slip shoes or slippers inside the house. Therefore, this statement indicates that the client needs further teaching.
Choice D Reason:
The client states, “I moved my medicine bottles into the living room.” While this might make the medications more accessible, it is not the safest practice. Medications should be stored in a cool, dry place, away from direct sunlight and moisture. Additionally, they should be kept in a location where they are easily visible and accessible but not in a high-traffic area where they could be knocked over. Therefore, this statement indicates that the client needs further teaching.
Choice E Reason:
The client states, “I switched to eating apples and oranges for a nighttime snack.” This is a positive dietary change. Apples and oranges are rich in vitamins and fiber, which are beneficial for overall health. This change also indicates an understanding of the need to incorporate more fruits into the diet. Therefore, this statement indicates that the client understood the teaching.
Choice F Reason:
The client states, “I placed a lamp on my bedside table.” This is a good practice as it ensures that the client has adequate lighting when getting in and out of bed, reducing the risk of falls. Therefore, this statement indicates that the client understood the teaching.
Choice G Reason:
The client states, “I prepared a large batch of beans, so I have a fast meal every night.” This is a positive change as it ensures that the client has a nutritious meal readily available, reducing the reliance on processed frozen meals. Beans are a good source of protein and fiber, which are important for overall health. Therefore, this statement indicates that the client understood the teaching.
Choice H Reason:
The client states, “I added a nonslip throw rug at my kitchen sink.” While the intention is good, throw rugs can still pose a tripping hazard, even if they are nonslip. It would be safer to use a mat that is securely fixed to the floor. Therefore, this statement indicates that the client needs further teaching.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Apply Bilateral Wrist Restraints
Applying bilateral wrist restraints can be necessary in some cases to prevent the child from touching or interfering with the surgical site. However, restraints should be used as a last resort and only when absolutely necessary. They can cause distress and discomfort to the child and should be monitored closely to prevent any complications.
Choice B reason: Administer Opioids for Pain
Administering opioids for pain management is a common practice post-surgery to ensure the child is comfortable. However, opioids should be used cautiously due to the risk of side effects and potential for dependency. Non-opioid pain management strategies, such as acetaminophen or ibuprofen, are often preferred unless the pain is severe.
Choice C reason: Implement a Soft Diet
Implementing a soft diet is crucial for a child who is 24 hours postoperative following a cleft palate repair. The surgical site in the mouth is still healing, and a soft diet helps prevent any damage or irritation to the area. Soft foods are easier to swallow and less likely to cause pain or disrupt the healing process. Examples of soft foods include mashed potatoes, yogurt, and pureed fruits.
Choice D reason: Offer Fluids Through a Straw
Offering fluids through a straw is not recommended for a child who has undergone cleft palate repair. The suction created by using a straw can put pressure on the surgical site and potentially cause complications. Instead, fluids should be offered using a cup or a spoon to minimize any risk to the healing palate.
Correct Answer is B
Explanation
Choice A reason: Hypophosphatemia
Hypophosphatemia, or low phosphate levels, is not typically associated with prerenal acute kidney injury (AKI). Prerenal AKI is primarily related to decreased blood flow to the kidneys, which does not directly affect phosphate levels. Hypophosphatemia is more commonly seen in conditions such as refeeding syndrome, chronic alcoholism, and certain endocrine disorders.
Choice B reason: Hyperkalemia
Hyperkalemia, or elevated potassium levels, is a common electrolyte imbalance in prerenal acute kidney injury (AKI). When kidney function is impaired, the kidneys are less able to excrete potassium, leading to its accumulation in the blood. This can result in dangerous cardiac arrhythmias and requires prompt management. Hyperkalemia is often seen in various types of AKI, including prerenal, intrinsic, and postrenal causes.
Choice C reason: Hypercalcemia
Hypercalcemia, or high calcium levels, is not typically associated with prerenal AKI. In fact, AKI can sometimes lead to hypocalcemia (low calcium levels) due to impaired kidney function affecting calcium and phosphate metabolism. Hypercalcemia is more commonly associated with conditions such as hyperparathyroidism, malignancies, and certain medications.
Choice D reason: Hypernatremia
Hypernatremia, or high sodium levels, is also not a typical finding in prerenal AKI. Prerenal AKI is usually characterized by volume depletion, which can lead to hyponatremia (low sodium levels) due to the body’s attempt to retain water and maintain blood pressure. Hypernatremia is more commonly seen in conditions involving excessive water loss or inadequate water intake.
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