Question

A nurse is providing teaching to a client who has stress incontinence. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Answer 1

Correct Answers:

“Attempt to void every 2 hours.”
“Take prescribed diuretics no later than 2000."
“Perform Kegel exercises several times daily."
"Maintain optimal body weight for height"

Rationale :

💧Timed voiding helps prevent involuntary leakage associated with stress incontinence by establishing a regular urination pattern.

🕗Diuretics should be taken early to prevent nocturnal diuresis, which can exacerbate incontinence and disturb sleep.

💪Kegel exercises strengthen pelvic floor muscles, directly addressing the loss of urethral control associated with stress incontinence.

⚖️Maintaining a healthy weight reduces abdominal pressure, which can lessen bladder pressure and the likelihood of leakage.

🚫Restricting fluid to 1000–1200 mL/day is not recommended as it can concentrate urine and worsen urinary irritation.

📌Core Message

Stress incontinence is best managed by promoting bladder training, performing pelvic muscle exercises, taking medications appropriately, and maintaining healthy body weight.

Answer 2

Correct Answers:

Initiate droplet precautions.
Assess the child for frequent swallowing.

Rationale :

😷Droplet precautions are crucial because epiglottitis is often caused by Haemophilus influenzae, a bacterium transmitted via respiratory droplets.

👅Frequent swallowing is a subtle but critical sign of impending airway obstruction due to pooling secretions or bleeding in the oropharyngeal region.

💁‍♂️Chest percussion and postural drainage are contraindicated as they can increase the risk of airway obstruction.

💊Pancreatic enzymes are used in conditions like cystic fibrosis, not epiglottitis.

📌Core Message

The management of epiglottitis involves initiating droplet precautions and continuously assessing for airway compromise through signs like frequent swallowing.

Answer 3

Correct Answers

Blank 1 Correct Option: meconium aspiration syndrome
Blank 2 Correct Option: Macrosomia

Rationale :

👶A post-term infant with meconium-stained fluid and late decelerations is at high risk for meconium aspiration syndrome, which can impair respiratory function.

📉Late decelerations and minimal variability are signs of fetal distress, likely due to placental insufficiency in a post-term pregnancy.

📏Infants born post-term are also at risk for macrosomia, which can lead to complications such as birth injuries or hypoglycemia.

💁‍♂️Bronchopulmonary dysplasia and intraventricular hemorrhage are typically associated with preterm infants, not post-term births.

📌Core Message

A post-term infant exposed to meconium-stained amniotic fluid is at risk for meconium aspiration and may also present with macrosomia due to prolonged fetal growth.

Answer 4

Correct Answers

Blank 1 Correct Option: Reye's syndrome
Blank 2 Correct Option: aspirin administration

Rationale :

🧠The toddler’s lethargy, vomiting, and history of aspirin use during a viral illness are classic signs of Reye’s syndrome, a rare but serious condition.

💊Aspirin use in children, especially with viral infections like influenza, is a well-established trigger for Reye’s syndrome.

🩺Manifestations such as vomiting, neurological deterioration, and elevated liver enzymes are commonly seen.

❌Reye's syndrome is not related to oseltamivir or acetaminophen administration.

📌Core Message

Reye’s syndrome is a serious complication triggered by aspirin use during viral infections in children, presenting with vomiting and neurologic changes.

Answer 5

Correct Answers

Encourage naps during the day when client is tired [ Not indicated ]
Instruct client to avoid foods that have been fermented or aged [ Not indicated ]
Encourage high-calorie finger foods [ Indicated ]
Encourage client to sleep until later in the morning [ Not indicated ]
Advise client to notify provider if pregnant [ Indicated ]
Encourage a regular sleep-wake schedule [ Indicated ]
Advise client to rise slowly from sitting [ Indicated ]

Rationale :

😴Trazodone, an antidepressant with sedative properties, is used to manage insomnia and depression, but promoting daytime naps can worsen nighttime sleep disturbances.

🧀There are no dietary restrictions related to fermented or aged foods for trazodone; such advice pertains to MAOIs, not trazodone.

🍽️Clients with appetite loss or weight loss, as seen here, benefit from high-calorie finger foods to increase nutritional intake.

🛌Encouraging later wake times disrupts circadian rhythm, which can worsen depressive symptoms and impair recovery.

🤰Clients of childbearing age should always be advised to inform their provider if pregnant, as medications may need adjustments.

🕓Establishing a regular sleep-wake schedule supports sleep hygiene and improves insomnia symptoms.

📉Trazodone can cause orthostatic hypotension, so the client should be advised to rise slowly to prevent dizziness or falls.

📌Core Message

When initiating trazodone, the nurse should promote nutritional intake, encourage a consistent sleep schedule, and monitor for hypotension and reproductive risks.

Answer 6

Correct Answers:

Establish alternatives to verbal conversation.

Rationale :

🗣️Expressive aphasia impairs the ability to speak or write but often leaves comprehension intact.

💬The best way to assist is to use alternative communication methods like picture boards or gestures.

📢A mechanical voice amplifier won't help if the client cannot form words.

📚Large print is irrelevant unless there's a vision impairment, which isn’t stated.

👓Glasses may help with reading but won't improve speech output.

📌Core Message

Clients with expressive aphasia benefit most from alternative communication strategies that compensate for lost verbal ability.

Answer 7

Correct Answers:

Limit the number of staff members providing care for the client.

Rationale :

🤝Following sexual assault, the client is likely to be experiencing trauma and emotional instability.

🚪Minimizing exposure to different caregivers supports a sense of control and privacy.

⚠️Asking for assault details too soon can retraumatize the client and should be handled by a trained forensic examiner.

🚿Clients should not shower or change before evidence collection to preserve forensic integrity.

💬Reassuring about non-life-threatening injuries minimizes the psychological impact and is less helpful than addressing emotional needs.

📌Core Message

Following a sexual assault, the nurse should reduce caregiver exposure to promote emotional safety and avoid further psychological harm.

Answer 8

Correct Answers:

Allow extra time for the client to perform tasks.
Touch the client gently to announce presence.
Keep objects in the client's room in the same place.

Rationale :

🕰️Allowing extra time ensures the client can maintain independence and safety while performing tasks.

✋Touching gently before speaking prevents startling, helping maintain orientation and calmness.

📦Keeping objects in consistent locations reduces confusion and potential falls.

💡High-wattage lighting can cause glare, making contrast perception worse for those with certain vision impairments.

👁️Approaching from the front, not the side, is recommended to help orient the client to the caregiver's presence.

📌Core Message

Effective care for clients with vision loss includes maintaining consistent environments, using gentle cues, and allowing adequate time for independence.

Answer 9

Correct Answers:

A client who has multiple facial lacerations.

Rationale :

🟢Clients tagged green in a disaster triage are those with non-life-threatening injuries and delayed treatment needs.

😷Facial lacerations, though potentially disfiguring, are not immediately life-threatening and can be managed later.

🦴A compound fracture involves bone protrusion and risk of infection, needing more urgent care.

🔥Full-thickness burns require immediate intervention for fluid resuscitation and airway protection.

💁‍♂️A puncture wound to the lung suggests pneumothorax, making it a higher priority.

📌Core Message

During disaster triage, clients with minor injuries like facial lacerations are given green tags indicating delayed but safe treatment.

Answer 10

Correct Answers:

Body mass index of 32

Rationale :

⚠️A BMI of 32 indicates obesity, a known risk factor for surgical wound infection due to decreased tissue perfusion and impaired wound healing.

🌡️A temperature of 36.8°C is within normal limits and does not indicate infection.

🦠A WBC of 8,000/mm³ falls within the normal range and does not indicate inflammation or infection.

🩸A blood glucose of 90 mg/dL is also within normal limits and does not increase infection risk.

📌Core Message

A BMI >30 is a significant risk factor for postoperative wound infections due to impaired healing and circulation.

Nursing Intervention	Indicated	Not indicated
Encourage naps during the day when client is tired
Instruct client to avoid foods that have been fermented or aged
Encourage high-calorie finger foods
Encourage client to sleep until later in the morning
Advise client to notify provider if pregnant
Encourage a regular sleep-wake schedule
Advise client to rise slowly from sitting

1 :
A nurse is providing teaching to a client who has stress incontinence. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

2 :
A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include in the child's care? Select all that apply

3 :
A nursery nurse 15 attending the birth of a post-term infant.

Correct Answers

4 :
A nurse is caring for a toddler in the outpatient setting.

Correct Answers

5 :
A nurse is caring for a client in the outpatient health clinic.

Correct Answers

6 :
A nurse is caring for a client who has expressive aphasia. Which of the following actions should the nurse take to assist the client in overcoming communication barriers?

7 :
A nurse on a mental health unit is planning care for a client who is being admitted immediately following a sexual assault. Which of the following interventions should the nurse include in the plan of care?

8 :
A nurse is caring for a client who has vison loss. Which of the following actions should the nurse take? (Select all that apply.)

9 :
A nurse has been assigned to an internal disaster drill team and is triaging clients. Which of the following clients should the nurse classify with a green tag?

10 :
A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse that the client is at risk for developing a surgical wound infection?

1 : A nurse is providing teaching to a client who has stress incontinence. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

2 : A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include in the child's care? Select all that apply

3 : A nursery nurse 15 attending the birth of a post-term infant.

Correct Answers

4 : A nurse is caring for a toddler in the outpatient setting.

Correct Answers

5 : A nurse is caring for a client in the outpatient health clinic.

Correct Answers

6 : A nurse is caring for a client who has expressive aphasia. Which of the following actions should the nurse take to assist the client in overcoming communication barriers?

7 : A nurse on a mental health unit is planning care for a client who is being admitted immediately following a sexual assault. Which of the following interventions should the nurse include in the plan of care?

8 : A nurse is caring for a client who has vison loss. Which of the following actions should the nurse take? (Select all that apply.)

9 : A nurse has been assigned to an internal disaster drill team and is triaging clients. Which of the following clients should the nurse classify with a green tag?

10 : A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse that the client is at risk for developing a surgical wound infection?

1 :
A nurse is providing teaching to a client who has stress incontinence. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

2 :
A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include in the child's care? Select all that apply

3 :
A nursery nurse 15 attending the birth of a post-term infant.

4 :
A nurse is caring for a toddler in the outpatient setting.

5 :
A nurse is caring for a client in the outpatient health clinic.

6 :
A nurse is caring for a client who has expressive aphasia. Which of the following actions should the nurse take to assist the client in overcoming communication barriers?

7 :
A nurse on a mental health unit is planning care for a client who is being admitted immediately following a sexual assault. Which of the following interventions should the nurse include in the plan of care?

8 :
A nurse is caring for a client who has vison loss. Which of the following actions should the nurse take? (Select all that apply.)

9 :
A nurse has been assigned to an internal disaster drill team and is triaging clients. Which of the following clients should the nurse classify with a green tag?

10 :
A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse that the client is at risk for developing a surgical wound infection?