An older woman who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and she only eats half of the food on her meal tray. Her family expresses concern about her nutritional status. How should the nurse respond to the family's concern?

Correct Answer: D

Rationale: In this scenario, the correct response is option D: Demonstrate the use of visual scanning during meals to the client and family. This is the most appropriate action because the client's difficulty with visual perception may be impacting her ability to see and recognize food on her plate, leading to decreased intake. By teaching the client and family how to use visual scanning techniques during meals, the nurse can help improve the client's ability to identify and consume food effectively. Option A: Encouraging the family to feed the client may undermine the client's independence and dignity. It is important to empower the client to feed themselves with appropriate assistance as needed. Option B: Suggesting that the family bring foods from home that the client enjoys does not address the underlying issue of visual perception difficulties. It is essential to address the root cause of the client's decreased food intake rather than simply offering different food options. Option C: Explaining that weight loss will be reversed after the acute phase of the stroke has ended does not provide immediate support or intervention for the client's current nutritional concerns. It is crucial to address the client's nutritional needs in the present moment to prevent further complications and promote recovery. In an educational context, understanding how to assess and address nutritional concerns in patients with neurological deficits, such as those following a CVA, is vital for pediatric cardiovascular nurses. Teaching effective strategies like visual scanning can significantly impact a patient's ability to maintain adequate nutrition and support their overall recovery and well-being.

Correct Answer: A

Rationale: In this scenario, the correct instruction for the nurse to emphasize during discharge teaching is option A) Check the insides and linings of all enclosed shoes before putting the shoes on. This instruction is crucial for a 70-year-old male client with type 2 diabetes mellitus (DM) who is hospitalized with an infected ulcer on his great right toe. Checking the insides and linings of shoes is important because it helps prevent pressure points, friction, and potential injury to the feet. Patients with diabetes, especially those with foot ulcers, are at higher risk for developing infections and complications due to reduced blood flow and nerve damage (neuropathy). Inspecting shoes ensures that no foreign objects are present that could cause further injury or infection. Option B is not the best choice because washing the feet with soap and water and applying a topical antibiotic ointment, although important for wound care, does not address preventive measures to avoid future foot injuries. Option C, trimming toenails weekly, may increase the risk of injury, especially for individuals with diabetes who may have impaired sensation or circulation in their feet. Option D, avoiding sandals or open-toed shoes, is not as critical as checking the insides of enclosed shoes. While open-toed shoes can expose the feet to potential injury, the primary focus should be on ensuring that the footwear worn provides adequate protection and support for the feet. In an educational context, emphasizing the importance of proper foot care and preventive measures is essential in managing diabetic foot complications. Educating patients on inspecting their shoes can help reduce the risk of ulcers and injuries, ultimately promoting better foot health and overall well-being for individuals with diabetes.

Correct Answer: D

Rationale: In the case of an adult client admitted with flank pain and diagnosed with acute pyelonephritis, the priority nursing action is to administer IV antibiotics as prescribed (Option D). This is because acute pyelonephritis is a bacterial infection of the kidneys that requires prompt antibiotic treatment to prevent complications such as sepsis or kidney damage. Administering antibiotics promptly is crucial to start combating the infection and prevent its progression. A) Auscultating for the presence of bowel sounds (Option A) is not the priority in this situation as the main concern is addressing the underlying infection in the kidneys. B) Monitoring hemoglobin and hematocrit (Option B) is important for assessing for anemia or blood loss, but it is not the priority in the immediate management of acute pyelonephritis. C) Encouraging turning and deep breathing (Option C) is a general nursing intervention to promote lung expansion and prevent respiratory complications but is not the priority action when dealing with a bacterial infection like pyelonephritis. In an educational context, it is essential for nursing students to understand the principles of prioritizing nursing actions based on the client's condition and needs. Understanding the pathophysiology of conditions like acute pyelonephritis and the rationale behind specific interventions helps students develop critical thinking skills and clinical judgment necessary for providing safe and effective patient care.

Correct Answer: B

Rationale: In pediatric cardiovascular nursing, monitoring intake and output is crucial in managing infants with heart failure on diuretic therapy. The most appropriate method to assess urine output in an infant is by weighing the diapers. This method allows for a non-invasive and continuous measurement of urine output, which is essential in detecting early signs of fluid imbalance in these vulnerable patients. Option A, inserting a foley catheter, is invasive and increases the risk of infection, especially in infants. It is not the first-line method for assessing urine output in this population. Option C, comparing intake with output, is important for overall fluid balance assessment but may not provide real-time information on urine output, which is crucial in infants with heart failure. Option D, measuring the amount of water added to the formula, does not directly measure urine output and may not accurately reflect the infant's true fluid status. Educationally, understanding the rationale behind choosing the appropriate method to assess urine output in infants with heart failure not only ensures accurate monitoring but also promotes safe and effective nursing care tailored to the specific needs of pediatric patients with cardiovascular conditions.

Correct Answer: A

Rationale: In the context of pediatric cardiovascular nursing, understanding the management of congenital heart defects like hypoplastic left heart syndrome is crucial. The correct answer to the question is A) Prostaglandin E. Prostaglandin E is given to keep the patent ductus arteriosus (PDA) open in infants with critical congenital heart defects, including hypoplastic left heart syndrome, to maintain pulmonary or systemic blood flow until surgical intervention can be performed. Indomethacin and ibuprofen, options B and C, are nonsteroidal anti-inflammatory drugs (NSAIDs) that are used to close a PDA by inhibiting prostaglandin synthesis. Therefore, they would be contraindicated in this scenario when we want to keep the PDA open. Digoxin, option D, is a medication commonly used in pediatric cardiology to treat heart failure by improving cardiac contractility. However, it is not the appropriate choice for keeping the PDA open in hypoplastic left heart syndrome. Educationally, it is essential for pediatric nurses to understand the rationale behind using specific medications in pediatric cardiovascular conditions to provide safe and effective care to this vulnerable population. Recognizing the pharmacological management of congenital heart defects and the medications involved is crucial for optimizing patient outcomes and preparing for potential complications.