1. Following discharge teaching, a male client with duodenal ulcer tells
the nurse the he will drink plenty of dairy products, such as milk, to
help
... [Show More] coat and protect his ulcer. What is the best follow-up action by
the nurse?
a- Remind the client that it is also important to switch to decaffeinated
coffee and tea.
b- Suggest that the client also plan to eat frequent small meals to
reduce discomfort
c- Review with the client the need to avoid foods that are rich in
milk and cream.
d- Reinforce this teaching by asking the client to list a dairy food that he
might select.
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and
should be avoided.
2. A male client with hypertension, who received new antihypertensive
prescriptions at his last visit returns to the clinic
two weeks later to evaluate his blood pressure (BP). His BP is 158/106
and he admits that he has not been taking the prescribed medication
because the drugs make him “feel bad”. In explaining the need for
hypertension control, the nurse should stress that an elevated BP
places the client at risk for which pathophysiological condition?
a- Blindness secondary to cataracts b- Acute kidney
injury due to glomerular damage c- Stroke
secondary to hemorrhage d- Heart block due to
myocardial damage
Rationale: Stroke related to cerebral hemorrhage is major risk for
uncontrolled hypertension.
3. The nurse observes an unlicensed assistive personnel (UAP)
positioning a newly admitted client who has a seizure disorder. The
client is supine and the UAP is placing soft pillows along the side
rails. What action should the nurse implement?
a- Ensure that the UAP has placed the pillows effectively to protect the
client.
b- Instruct the UAP to obtain soft blankets to secure to the side rails
instead of pillows.
a- Assume responsibility for placing the pillows while the UAP
completes another task.
b- Ask the UAP to use some of the pillows to prop the client in a side
lying position.
Rationale: The nurse should instruct the UAP to pad the side rails with soft
blankest because the use of pillows could result in suffocation and would
need to be removed at the onset of the seizure. The nurse can delegate
paddling the side rails to the UAP
4. An adolescent with major depressive disorder has been taking
duloxetine (Cymbalta) for the past 12 days. Which assessment
finding requires immediate follow-up?
a- Describes life without purpose
b- Complains of nausea and loss of appetite cStates is often fatigued and drowsy d- Exhibits
an increase in sweating.
Rationale: Cymbalta is a selective serotonin and norepinephrine
reuptake inhi [Show Less]