Nokea
To ensure client safety, which assessment is most important for the nurse to make before advancing a client from liquid to solid food?
- A. Bowel sounds
- B. Chewing ability
- C. Current appetite
- D. Food preferences
Correct Answer: B
Rationale: The nurse needs to assess the client's chewing ability before advancing a client from liquid to solid food. It may be necessary to modify a client's diet to a soft or mechanical chopped diet if the client has difficulty chewing because of the risk of aspiration. Bowel sounds should be present before introducing any diet, including liquids. Appetite will affect the amount of food eaten, but not the type of diet prescribed. Food preferences should be ascertained on admission assessment.
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A magnetic resonance imaging (MRI) scan is prescribed for a client with a suspected brain tumor. Which prescription should the nurse anticipate will be prescribed for the client before the procedure?
- A. An opioid
- B. A sedative
- C. A corticosteroid
- D. An antihistamine
Correct Answer: B
Rationale: An MRI scan is a noninvasive diagnostic test that visualizes the body's tissues, structure, and blood flow. For an MRI, the client is positioned on a padded table and moved into a cylinder-shaped scanner. Relaxation techniques, an eye mask, and sedation are used before the procedure to reduce claustrophobic effects; however, because the client must remain very still during the scan, the nurse avoids oversedating the client to ensure client cooperation. There is no useful purpose for administering an opioid, corticosteroid, or antihistamine.
The nurse performing a prenatal assessment on a client in the first trimester of pregnancy discovers that the client frequently consumes beverages containing alcohol. Why should the nurse initiate interventions immediately to assist the client in avoiding alcohol consumption?
- A. To reduce the potential for fetal growth restriction in utero
- B. To promote the normal psychosocial adaptation of the mother to pregnancy
- C. To minimize the potential for placental abruptions during the intrapartum period
- D. To reduce the risk of teratogenic effects to embryo's developing fetal organs and tissue
Correct Answer: D
Rationale: Alcohol consumption during the first trimester poses a significant risk for teratogenic effects, as this is a critical period for organogenesis in the developing embryo. Exposure to alcohol can lead to fetal alcohol syndrome or other congenital anomalies, making immediate intervention essential to protect fetal development. While fetal growth restriction, psychosocial adaptation, and placental abruption are concerns, they are less directly associated with early pregnancy alcohol exposure compared to teratogenic effects.
The nurse is reviewing the records of recently admitted clients to the postpartum unit. The nurse determines that which clients would have an increased risk for developing a puerperal infection? Select all that apply.
- A. A client with a history of previous infections
- B. A client who has given birth to a set of twins
- C. A client who had numerous vaginal examinations
- D. A client who has experienced three previous miscarriages
- E. A client who underwent a vaginal delivery of the newborn
- F. A client who experienced prolonged rupture of the membranes
Correct Answer: A,C,F
Rationale: Risk factors associated with puerperal infection include a history of previous infections, excessive number of vaginal examinations, cesarean births, prolonged rupture of the membranes, prolonged labor, trauma, and retained placental fragments. A vaginal delivery, a history of miscarriages, and the delivery of twins are not considered as risk factors for developing a puerperal infection.
A client is brought into the emergency department after sustaining a possible closed head injury. Which assessment will the nurse perform first?
- A. Level of consciousness
- B. Pulse and blood pressure
- C. Respiratory rate and depth
- D. Ability to move extremities
Correct Answer: C
Rationale: The first action of the nurse is to ensure that the client has an adequate airway and respiratory status. In rapid sequence, the client's circulatory status is evaluated (option 2), followed by evaluation of the status of the cardiovascular and neurological systems.
The nurse caring for a client diagnosed with a neurological disorder is planning care to maintain nutritional status. The nurse is concerned about the client's swallowing ability. Which food item should the nurse eliminate from this client's diet?
- A. Spinach
- B. Custard
- C. Scrambled eggs
- D. Mashed potatoes
Correct Answer: A
Rationale: Raw vegetables; chunky vegetables such as diced beets; and stringy vegetables such as spinach, corn, and peas are foods commonly excluded from the diet of a client with a poor swallowing reflex. In general, flavorful, warm, or well-chilled foods with texture stimulate the swallowing reflex. Soft and semisoft foods such as custards or puddings, egg dishes, and potatoes are usually effective.