Nokea
A 16-year-old Hispanic client at 10 weeks' gestation has been diagnosed with mild iron deficiency anemia. The client tells the nurse that she doesn't like to eat much meat. Which of the following foods should the nurse suggest to provide the client with the greatest amount of iron in her diet?
- A. 1 cup of lentils
- B. 1 cup of sunflower seeds
- C. 1/2oz of hard cheese
- D. 2 poached eggs
Correct Answer: A
Rationale: Lentils are a rich plant-based source of iron, providing significantly more iron per serving than sunflower seeds, cheese, or eggs, making them ideal for a client avoiding meat.
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A nurse is assessing a client with metastatic lung cancer. The nurse should assess the client for:
- A. Diarrhea.
- B. Constipation.
- C. Hoarseness.
- D. Weight gain.
Correct Answer: C
Rationale: Hoarseness is a common symptom of metastatic lung cancer due to tumor effects on the larynx or recurrent laryngeal nerve. Constipation, diarrhea, and weight gain are less specific.
A usually reliable interpreter called by the nurse to help communicate with a mother of a child who does not speak English and has brought her child in for a routine visit has yet to arrive in the clinic. The nurse has paged the interpreter several times. Which of the following should the nurse do next?
- A. Continue with the examination.
- B. Reschedule the infant's appointment for later in the week.
- C. Ask the mother to stay longer in the hope that the interpreter arrives.
- D. Page the interpreter one more time.
Correct Answer: B
Rationale: Rescheduling ensures effective communication with the interpreter, avoiding potential misunderstandings during the visit.
A client with a diagnosis of acquired immunodeficiency syndrome and cytomegalovirus retinitis is receiving ganciclovir. Which action should the nurse plan to take while the client is taking this medication?
- A. Monitor blood glucose levels for elevation.
- B. Administer the medication on an empty stomach only.
- C. Apply pressure to venipuncture sites for at least 2 minutes.
- D. Provide the client with a soft toothbrush and an electric razor.
Correct Answer: D
Rationale: Ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects. For this reason, the nurse monitors the client for signs and symptoms of bleeding and implements the same precautions that are used for a client receiving anticoagulant therapy. These include providing a soft toothbrush and electric razor to minimize the risk of trauma that could result in bleeding. The medication may cause hypoglycemia, not hyperglycemia. The medication does not have to be taken on an empty stomach. Venipuncture sites should be held for approximately 10 minutes.
A client with chronic undifferentiated schizophrenia is having an acute exacerbation of symptoms. The client states, 'Black cats and black hats. Where does the time go?' Which of the following would be most important for the nurse to say?
- A. Halloween is getting close, isn't it.'
- B. Do you have a black cat?'
- C. What's the connection between cats, hats, and time?'
- D. Time certainly does go faster these days.'
Correct Answer: C
Rationale: Clarifying the client's statement helps assess their thought process and engage therapeutically.
You have decided to use the Dimensions Model of Health model to assess, monitor and evaluate the health status of the community. Which of these dimensions is NOT an element of this Dimensions Model of Health model?
- A. The Biophysical Dimension
- B. The Psychological and Emotional Dimension
- C. The Spiritual Dimension
- D. The Health Systems Dimension
Correct Answer: D
Rationale: The Dimensions Model of Health typically includes biophysical, psychological, social, and spiritual dimensions. The Health Systems Dimension is not a standard component of this model.