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The nurse is preparing the client for discharge.

Which of the following statements indicate the client understands the discharge teaching?

Select the 3 client statements that indicate an understanding of the teaching.

"I will need to take my medications for a total of 6 weeks."

“I am no longer contagious."

"I will need to have someone observe me when I take my medication."

"I can expect my contact lenses to turn red or orange,"

"I should notify my provider if I start taking new over-the-counter or prescription medications."

"I can continue my current alcohol intake."

"I will need to have a repeat Mantoux test in 4 weeks."

Answer and Explanation

Correct Answer : C,D,E

A. "I will need to take my medications for a total of 6 weeks.": TB treatment requires a prolonged course, typically 6 months, not 6 weeks. This statement reflects a misunderstanding of the duration of therapy and could lead to incomplete treatment and drug resistance.

B. “I am no longer contagious.": Clients with active tuberculosis remain contagious until they have received adequate treatment and follow-up testing confirms noninfectious status. Early discharge does not automatically mean the client is no longer a transmission risk.

C. "I will need to have someone observe me when I take my medication.": Directly Observed Therapy (DOT) is recommended to ensure adherence to TB medications, which helps prevent drug resistance and treatment failure. Understanding the importance of DOT indicates comprehension of infection control and treatment compliance.

D. "I can expect my contact lenses to turn red or orange.": Rifampin can discolor body fluids, including tears, causing contact lenses to appear red or orange. Recognizing this harmless side effect demonstrates the client’s understanding of medication effects.

E. "I should notify my provider if I start taking new over-the-counter or prescription medications.": TB medications have multiple drug interactions, and the client must inform the provider of any new medications to prevent adverse effects or reduced drug efficacy.

F. "I can continue my current alcohol intake.": Alcohol use is contraindicated with TB medications because it increases the risk of hepatotoxicity, particularly with isoniazid, rifampin, and pyrazinamide. Continuing alcohol would compromise treatment safety.

G. "I will need to have a repeat Mantoux test in 4 weeks.": Follow-up testing is not required once TB is confirmed by sputum culture. The Mantoux test is used for diagnosis, not monitoring treatment response.

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Correct Answer is D

Explanation

A. Visual Analog Scale: The visual analog scale requires the child to understand and mark a point on a line representing pain intensity. This scale is appropriate for older children, usually around 7 years and older, and not for an 8-month-old infant.

B. FACES pain scale: The FACES scale uses facial expressions to help children identify pain intensity, but it is suitable for children aged 3 years and older who can understand the concept of choosing a face to represent their pain.

C. Oucher scale: The Oucher scale also relies on the child’s ability to self-report pain by selecting a photograph or numerical representation. It is not appropriate for infants who cannot communicate their pain cognitively.

D. FLACC scale: The FLACC scale assesses pain in infants and young children by observing five criteria: Face, Legs, Activity, Cry, and Consolability. It allows the nurse to evaluate pain objectively in an 8-month-old who cannot verbally self-report.

A. Deliver 2 L of oxygen via partial nonrebreather mask B. Give epinephrine intramuscularly C. Notify the radiology department. D. Administer diazepam PO.

Correct Answer is B

Explanation

A. Deliver 2 L of oxygen via partial nonrebreather mask: While supplemental oxygen may support oxygenation, it does not treat the underlying life-threatening allergic reaction. Oxygen alone is insufficient for anaphylaxis and should not delay definitive treatment.

B. Give epinephrine intramuscularly: Epinephrine is the first-line treatment for anaphylaxis and rapidly counteracts airway constriction, hypotension, and vascular permeability. Intramuscular administration in the mid-outer thigh provides rapid absorption and is essential to prevent respiratory compromise and shock.

C. Notify the radiology department: Notifying radiology is unrelated to the acute management of an allergic reaction. Immediate intervention to secure the airway and treat anaphylaxis takes priority over nonessential notifications.

D. Administer diazepam PO: Diazepam is an anxiolytic and has no role in managing anaphylaxis or airway obstruction. It does not reverse histamine-mediated effects and would delay critical emergency treatment.

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The nurse is preparing the client for discharge. Which of the following statements indicate the client understands the discharge teaching? Select the 3 client statements that indicate an understanding of the teaching.

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The nurse is preparing the client for discharge.

Which of the following statements indicate the client understands the discharge teaching?

Select the 3 client statements that indicate an understanding of the teaching.