Which statement by a patient with osteoporosis indicates the need for additional teaching?

Correct Answer: A

Rationale: The correct answer is A) "I take my ibuprofen every morning as soon as I get up." This statement indicates the need for additional teaching because ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal issues, such as ulcers or bleeding, especially in individuals with osteoporosis who are already at a higher risk for fractures. It is crucial for patients with osteoporosis to be aware of the potential side effects of medications and to consult their healthcare provider before taking any new medication. Option B) "My daughter removed all of the throw rugs in my home" is a positive statement as removing throw rugs reduces the risk of falls, which is essential for individuals with osteoporosis who are at a higher risk of fractures due to decreased bone density. Option C) "My husband helps me every afternoon with range-of-motion exercises" is also a positive statement as range-of-motion exercises can help improve flexibility, strength, and balance, which are all beneficial for individuals with osteoporosis to maintain bone health and prevent falls. Option D) "I rest in my recliner chair every day for at least an hour" is not necessarily an incorrect statement, but it does not address the management or prevention of osteoporosis. Weight-bearing and muscle-strengthening activities are more critical for individuals with osteoporosis to maintain bone density and overall health. In an educational context, it is important to emphasize to patients with osteoporosis the importance of medication safety, fall prevention strategies, appropriate exercise routines, and a healthy, balanced lifestyle to manage their condition effectively and reduce the risk of complications. Encouraging open communication with healthcare providers for any concerns or questions about their treatment plan is also crucial for optimal management of osteoporosis.

Correct Answer: B

Rationale: The correct answer is B) By moving the head and chin of the client towards the chest. This action is known as the Kernig's sign, a specific test for assessing stiffness and rigidity of the neck, which can indicate conditions such as meningitis or other neurological issues. By flexing the neck in this manner, the nurse can observe the client's response for any resistance or discomfort, providing valuable information about the client's neurological status. Option A is incorrect because positioning the client flat on the bed for hours does not specifically assess stiffness and rigidity of the neck. It may lead to discomfort and immobility-related issues but does not target the neurological assessment needed. Option C is incorrect as asking the client to bend and pick up objects on the floor assesses motor function and flexibility but does not specifically target the stiffness and rigidity of the neck. Option D is incorrect as introducing a painful stimulus on the neck is not a standard or appropriate method for assessing stiffness and rigidity. It can cause unnecessary discomfort and is not a recommended practice in neurological assessments. Understanding how to properly assess neurological signs and symptoms is crucial for nurses to provide accurate care and interventions for clients with neurological conditions. Conducting assessments like Kernig's sign correctly can help in early detection and appropriate management of neurological issues, emphasizing the importance of thorough and accurate assessments in nursing practice.

Correct Answer: B

Rationale: In the case of a client diagnosed with encephalitis, the most critical nursing intervention is option B: Observing closely for signs of respiratory distress. Encephalitis is an inflammation of the brain that can lead to serious complications, including respiratory compromise. Monitoring for signs of respiratory distress such as increased respiratory rate, use of accessory muscles, cyanosis, and changes in oxygen saturation is crucial for early detection and intervention to prevent respiratory failure. Option A, evaluating ventilation capacity and lung sounds, is important but not as critical as monitoring for respiratory distress in this scenario. Encephalitis primarily affects the brain, so focusing on respiratory distress takes precedence over routine assessment of lung sounds. Option C, administering an indwelling urethral catheter, is not directly related to the priority issue of respiratory distress in a client with encephalitis. While urinary elimination is important, it is not the most critical concern in this situation. Option D, monitoring vital signs and level of consciousness (LOC) frequently, is a general nursing intervention that is important in many situations, including encephalitis. However, in this case, monitoring specifically for signs of respiratory distress takes precedence over general vital sign assessment due to the potential for rapid deterioration in respiratory status. Educationally, it is important for nurses to understand the prioritization of interventions based on the client's condition. This rationale highlights the critical thinking process involved in determining the most urgent nursing intervention for a specific diagnosis like encephalitis. Nurses must be able to quickly identify and respond to the most pressing issues to ensure optimal patient outcomes.

Correct Answer: C

Rationale: The most appropriate nursing instruction to manage a young male client with chronic tension headaches is option C) Counseling on alternate therapies. This is the correct answer because chronic tension headaches often have a strong connection to stress and muscle tension. By counseling the client on alternate therapies such as relaxation techniques, mindfulness, acupuncture, or massage therapy, the nurse can address the root cause of the headaches and provide non-pharmacological methods for managing pain and stress. Option A) Instructing the client to monitor for signs of bruising or bleeding is incorrect as it is not relevant to tension headaches. Option B) Suggesting eating and swallowing techniques that reduce the potential for aspiration is also incorrect as it is more related to dysphagia, not tension headaches. Option D) Advising the client to change sleeping positions frequently may help with other conditions like neck pain but is not directly related to managing tension headaches. In an educational context, it is important for nurses to understand the underlying causes of common health issues like tension headaches and to be able to provide holistic care that includes both pharmacological and non-pharmacological interventions. Counseling on alternate therapies empowers the client to take an active role in managing their health and promotes a more comprehensive approach to healthcare.

Correct Answer: B

Rationale: In the management of ischemic stroke, the administration of tissue plasminogen activator (TPA) is crucial in improving outcomes. The correct answer is B) 3 hours. This is because TPA is most effective when given within the first 3 hours of symptom onset. Administering TPA within this time frame can help dissolve the blood clot causing the ischemic stroke and restore blood flow to the affected area of the brain, minimizing long-term damage. Option A) 6 hours is incorrect because waiting this long reduces the efficacy of TPA and increases the risk of complications. Option C) 8 hours and Option D) 10 hours are even further beyond the optimal window for TPA administration, significantly decreasing its effectiveness. Educationally, understanding the time-sensitive nature of TPA administration emphasizes the importance of rapid assessment, diagnosis, and treatment in stroke care. This knowledge underscores the critical role of healthcare providers in recognizing and responding promptly to stroke symptoms to maximize the chances of a positive outcome for the patient.