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When admitting a client at risk for falls in a long-term care facility, what should the nurse do first?
- A. Complete a fall-risk assessment
- B. Place a fall-risk identification bracelet on the client
- C. Provide the client with nonskid footwear
- D. Set the bed to the lowest position
Correct Answer: A
Rationale: The initial step in caring for a client at risk for falls is to conduct a fall-risk assessment. This assessment helps the nurse gather crucial data to identify specific risks and individualized needs, guiding subsequent interventions and preventive measures. By completing a thorough assessment, the nurse can develop a targeted plan of care to mitigate fall risk and ensure the client's safety. Placing a fall-risk identification bracelet, providing nonskid footwear, or setting the bed to the lowest position may be important interventions, but these actions should be based on the findings of the fall-risk assessment, making choice A the priority.
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Indicate true or false: (Adapted: Which statement is true about IV solutions?)
- A. Hypotonic solutions should be replaced intracellular fluid loss.
- B. Smaller veins are ideal for intravenous solutions that are irritating.
- C. Both statements are true.
- D. Neither statement is true.
Correct Answer: A
Rationale: Hypotonic solutions (e.g., 0.45% saline) shift fluid into cells, replacing intracellular loss (e.g., dehydration), making this true ideal for cellular rehydration. Smaller veins aren't ideal for irritating solutions (e.g., potassium); larger veins dilute and tolerate them better, reducing phlebitis making this false. Adapting the true/false format, 'hypotonic solutions should replace intracellular loss' stands as true, supported by fluid dynamics in nursing. Both being true fails due to the vein statement. Neither true ignores the hypotonic role. The first statement's accuracy aligns with IV therapy principles, guiding nurses in fluid management, making it the correct choice.
A healthcare professional is planning care for a client who has a new prescription for a low-sodium diet. Which of the following foods should the healthcare professional recommend?
- A. Canned soup
- B. Fresh fruit
- C. Pickles
- D. Soy sauce
Correct Answer: B
Rationale: Fresh fruit is naturally low in sodium and is a suitable choice for a low-sodium diet. It provides essential nutrients without adding significant amounts of sodium, making it a healthy option for individuals following a low-sodium diet. Canned soup, pickles, and soy sauce are high in sodium content and should be avoided by individuals on a low-sodium diet. Canned soups are often loaded with added salt, pickles are preserved in brine containing high sodium levels, and soy sauce is a condiment with a high sodium content.
A client is receiving discharge teaching after a total hip arthroplasty. Which of the following instructions should be included?
- A. Cross your legs at the ankles while sitting
- B. Avoid bending your hips more than 90 degrees
- C. Sit in a low-seated chair
- D. Twist your body when standing up
Correct Answer: B
Rationale: To prevent dislocation of the hip prosthesis, the client should avoid bending their hips more than 90 degrees. Excessive bending at the hips can increase the risk of hip dislocation, which is a significant concern following total hip arthroplasty. Sitting with crossed legs at the ankles (choice A) can also increase the risk of hip dislocation and should be avoided. Sitting in a low-seated chair (choice C) can make it more challenging for the client to stand up safely. Twisting the body when standing up (choice D) can also strain the hip joint and increase the risk of dislocation. Therefore, the correct instruction to include during discharge teaching is to avoid bending the hips more than 90 degrees.
What is a dynamic balance among the physical, psychological, social, and spiritual aspects of a person's life?
- A. Health
- B. Wellness
- C. Holism
- D. Health promotion
Correct Answer: B
Rationale: Wellness is a dynamic balance of physical, psychological, social, and spiritual aspects, reflecting an active pursuit of optimal living like exercising, managing stress, connecting socially, and finding purpose. Health is a broader state of well-being, per WHO, not inherently dynamic. Holism is a care philosophy addressing all dimensions, not the state itself. Health promotion involves interventions to improve health, not the balance. Wellness captures an individual's journey toward harmony, as when a nurse helps a client integrate diet (physical), support groups (social), coping skills (psychological), and values (spiritual). This concept guides nursing to foster resilience and fulfillment, distinct from static health or care approaches, emphasizing personal agency in thriving.
A client with diverticulitis is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of high-fiber foods.
- B. I should decrease my intake of high-fiber foods.
- C. I should increase my intake of high-fat foods.
- D. I should decrease my intake of high-fat foods.
Correct Answer: A
Rationale: The correct answer is A. Increasing intake of high-fiber foods is essential in managing diverticulitis as it helps prevent constipation and promotes bowel regularity, reducing the risk of complications and improving overall colon health. Choice B is incorrect because decreasing high-fiber foods can worsen diverticulitis symptoms. Choices C and D are also incorrect as increasing high-fat foods can exacerbate diverticulitis, while decreasing high-fat foods is generally recommended to manage the condition.