The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that:

Correct Answer: D

Rationale: In caring for a client with cirrhosis of the liver and ascites, the correct answer is D) The client may ambulate as tolerated and remain in semi-Fowler's position in bed. This option is correct because allowing the client to ambulate as tolerated helps prevent complications such as deep vein thrombosis and muscle atrophy. Additionally, maintaining a semi-Fowler's position in bed helps reduce abdominal fluid accumulation and improves respiratory function. Option A is incorrect because complete bed rest can lead to deconditioning and other complications. Option B is incorrect as elevating the legs for prolonged periods can impede circulation. Option C is also incorrect as it does not address the need to manage ascites and maintain proper positioning. Educationally, it is important to understand the rationale behind the care of clients with cirrhosis and ascites to promote optimal outcomes. Nurses should emphasize the importance of a balance between ambulation and rest, as well as the significance of positioning in managing symptoms and preventing complications. This knowledge helps nursing assistants provide safe and effective care to clients with these conditions.

Correct Answer: D

Rationale: In teaching parents to associate prevention with the lifestyle of their child with sickle cell disease, emphasizing the priority of maintaining routine immunizations (Option D) is crucial. Sickle cell disease compromises the immune system, making individuals more susceptible to infections. By ensuring routine immunizations, the child is better protected against preventable diseases, reducing the risk of complications associated with sickle cell disease. Avoiding overheating during physical activities (Option A) is important in managing sickle cell disease to prevent a crisis, but routine immunizations take precedence in overall preventive care. Maintaining normal activity with some restrictions (Option B) is relevant but not as vital as ensuring immunizations for overall health. Being cautious of others with viruses or temperatures (Option C) is important but does not address the proactive preventive measure of routine immunizations. In an educational context, this rationale highlights the significance of preventive care in managing sickle cell disease. By prioritizing routine immunizations, parents can actively protect their child from potential health risks associated with the condition, promoting overall well-being and quality of life.

Correct Answer: C

Rationale: In educating a client about lithium, it is crucial to provide accurate information regarding its onset of action. The correct response is C) 2 weeks. This is because lithium is a mood stabilizer commonly used in the treatment of bipolar disorder. It typically takes around 1 to 2 weeks for lithium to reach therapeutic levels in the blood and start exerting its therapeutic effects on mood stabilization. Option A) Immediately is incorrect because lithium does not work instantaneously like some medications. Option B) Several days is also incorrect as it may not fully capture the typical time frame for lithium to become effective. Option D) 1 month is too extended of a timeline for the onset of action of lithium. Educationally, understanding the onset of action of medications is essential for both healthcare providers and clients to set realistic expectations regarding treatment outcomes. Providing accurate information empowers clients to make informed decisions about their health and treatment plans. It also helps in promoting medication adherence and managing expectations during the treatment process.

Correct Answer: C

Rationale: In assessing the healing of a client's wound during a home visit, the best indicator of good healing is reddened tissue (Option C). Reddened tissue indicates that there is adequate blood flow to the area, which is essential for the delivery of oxygen and nutrients necessary for wound healing. This redness is a sign of the inflammatory phase of healing, where the body is actively working to repair the damaged tissue. White patches (Option A) may indicate the presence of pus or infection, which is a sign of poor healing and requires further assessment and intervention. Green drainage (Option B) is often a sign of infection as well, suggesting the presence of bacteria in the wound that can impede the healing process. Eschar development (Option D) refers to the formation of a hard, blackened crust over a wound, which can hinder healing by preventing new tissue growth. Educationally, understanding these indicators of wound healing is crucial for healthcare providers to make informed decisions about wound care interventions. Teaching students to recognize these signs helps to ensure proper assessment and timely intervention to promote effective wound healing and prevent complications.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) S3 heart sound. When a client develops volume overload from rapid IV infusion, their heart may become overwhelmed by the increased volume, leading to impaired ventricular filling and increased pressure in the heart chambers. This can result in the development of an S3 heart sound, also known as a ventricular gallop, which is an extra heart sound heard in early diastole. Option B) Thready pulse is incorrect because a thready pulse is typically associated with decreased volume or poor perfusion, not volume overload. Option C) Flattened neck veins is incorrect because in volume overload, the client is likely to exhibit distended neck veins due to increased venous return to the heart. Option D) Hypoventilation is incorrect as it is not directly related to volume overload. Hypoventilation refers to inadequate breathing, which can lead to increased carbon dioxide levels in the blood. Educationally, understanding the assessment findings associated with volume overload is crucial for nurses caring for patients receiving IV fluids. Recognizing the subtle signs such as an S3 heart sound can prompt early intervention to prevent complications like heart failure. This knowledge helps nurses provide safe and effective care, ensuring optimal patient outcomes.