Basic care Q bank

The home care nurse assesses a client diagnosed with gout. The nurse is MOST concerned if the client states which of the following? "I am losing 3 pounds per week." "I drink 8 glasses of liquid per day." "I am eating more whole grains and fresh fruits." "I do not drink alcoholic beverages any more."

1 am losing 3 punds per week (should only lose .5-1 lb per week)

albumin level

3.5-5.5

The nurse performs discharge teaching for the client diagnosed with multiple sclerosis. It is MOST important for the nurse to include which instruction? Ambulate as tolerated every day. Avoid overexposure to heat or cold. Perform stretching and strengthening exercises. Participate in social activities.

avoid overexposure to heat or cold -want them to exercise and socialize, do stress management -

celiacs diet

high calorie, high protein -NO RYE, WHEAT, OAT, BARLEY

The home care nurse visits the client diagnosed with heart failure who lives in an independent living facility. The client reports constipation, and the nurse further assesses to determine the cause of the constipation. The nurse is most concerned if the client makes which statement? "I walk at sunrise every day." "I drink eight glasses of fluid each day." "I never go to the salad bar." "I play bridge almost every day."

i never go to the salad bar -need fiber from fruits and veggies, grains

A patient diagnosed with myasthenia gravis prepares for discharge from the rehabilitation unit to living at home with her daughter. The nurse reviews with the daughter necessary home modifications, as well as ambulation issues. Which of the following statements by the daughter indicates to the nurse that further teaching is necessary? "I will go forward in and out of elevators, pushing Mother's wheelchair carefully in front of me." "I will fold the footrests away when my mother is getting in and out of the wheelchair." "If we are somewhere with an electric self-closing glass door, I will back myself into it as we go through." "I will be sure my mother is sitting as far back in the wheelchair as is possible."

i will go foward in and our of elevators pushing mothers wheelchair in front of me -always back into an elevator--wheelchair last

The nurse on the neurology unit prepares a patient for discharge. The patient has been treated for an exacerbation of multiple sclerosis. Which of the following statements, if made by the patient to the nurse, indicates that teaching is successful? "When I am exercising, I will push a little beyond when I start to feel tired and then stop." "When my muscles seem especially spastic, I will take hot baths to relieve them." "I will sleep on my stomach as much as I can." "I will be firm and steady when I pull a spastic leg open."

i will sleep on my stomach as much as i can r/t min spasms avoid pressure ulcers -NEVER PULL A SPASTIC EXTREMITY OPEN -rotate toward direction then opposite direction

The nurse cares for a client 2 days after the client sustained an injury in an auto accident. The client is placed in halo vest traction. The nurse is MOST concerned if the client states which of the following? "It hurts when I chew." "My back itches." "I have a headache." "Why did this happen to me?"

it hurts when i chew -SHOULDNT HAVE JAW PAIN TWO DAYS POST -the doctor tightens screws at 2 days so headache to be expected-give analgesic

The home care nurse visits a client diagnosed with Parkinson's disease. The client's husband states that even though his wife eats, she is losing weight. Which of the following suggestions by the nurse is MOST appropriate? Instruct the husband to offer the client thick milkshakes. Inform the husband that this is to be expected. Observe the client feed herself. Refer the client to the dietician.

observe client feed herself -may be dropping food in lap

The nurse on the surgical unit is aware that protein-calorie malnutrition contributes to postoperative infections. Which observation best informs the nurse that the client's protein intake is adequate? The client eats 1/2 to 3/4 of the food on each meal tray. The client has dry, flaking skin. The client complains of being cold. The client's serum albumin is 4.0 g/dL (40 g/L).

serum albumin is 4.0 -most objective