The husband and adult children of a woman who abuses alcohol ask the nurse what approach to use when her drinking behavior disrupts family plans. Which response is best for the nurse to provide?

Correct Answer: C

Rationale: The best approach for the nurse to suggest is to make the woman responsible for the consequences of her drinking behaviors. By holding her accountable, she is more likely to recognize the impact of her actions and potentially initiate change. Destroying hidden alcohol supplies (Choice A) might lead to conflict and further secretive behavior. Simply communicating the disruptions caused by her drinking (Choice B) may not effectively address the issue. Including her in family activities regardless of her drinking status (Choice D) could enable the behavior and not address the underlying problem.

Correct Answer: B

Rationale: Yes, it is important to continue straining all urine to catch any remaining stones. Straining the urine helps in identifying any new stones that may have formed, allowing for appropriate management. While measuring intake and output is important, straining the urine is specifically necessary in this case to monitor the presence of kidney stones. Ensuring the client is free from pain is essential, but in this situation, preventing further complications related to kidney stones is a higher priority.

Correct Answer: D

Rationale: Bilirubin is a key serum laboratory value that is likely to be elevated in clients with jaundice. Jaundice is characterized by a yellowish discoloration of the skin and eyes due to an excess of bilirubin, a breakdown product of hemoglobin. Elevated amylase levels are associated with pancreatic conditions, not specifically jaundice. Creatinine and blood urea nitrogen are markers of kidney function and are not directly related to jaundice.

Correct Answer: A

Rationale: The correct answer is A. Rifampin (Rifadin) commonly causes a reddish-orange discoloration of body fluids, including urine, sweat, saliva, and tears. This is a harmless side effect but should be reported to the healthcare provider for monitoring. Choices B, C, and D are not typically associated with rifampin therapy. Bloody or blood-tinged urine may indicate other issues such as urinary tract infection or kidney problems, blurring of vision may suggest eye problems, and significant weight gain could be related to various health conditions unrelated to rifampin.

Correct Answer: C

Rationale: The correct answer is C) Refrain from sexual intercourse until your next appointment. Explanation: For a client with partial placenta previa at 32 weeks of pregnancy, it is crucial to avoid activities that can potentially disrupt the placenta and cause bleeding. Sexual intercourse can lead to trauma to the cervix, increasing the risk of bleeding in cases of placenta previa. This instruction is essential to prevent complications and ensure the safety of both the mother and the baby. Why others are wrong: A) Wearing a tight abdominal binder can increase pressure on the placenta, potentially leading to bleeding. It is not recommended in cases of placenta previa. B) Taking a daily laxative is unrelated to the management of partial placenta previa and may not be necessary or safe during pregnancy. D) Restricting fluids to less than 1000 ml per day can lead to dehydration, which is not advisable during pregnancy, especially with a condition like placenta previa that requires close monitoring of fluid status and blood loss. Educational context: Understanding the management of complications during pregnancy, such as placenta previa, is crucial for nurses in providing safe and effective care to pregnant clients. Educating clients about lifestyle modifications and activities to avoid is essential in preventing adverse outcomes and promoting maternal and fetal well-being. Nurses play a key role in patient education and must ensure that clients comprehend the rationale behind these instructions to comply with them effectively.