Nokea
A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
- A. Tell me about his pain.
- B. What does his vomit look like?
- C. Describe his usual diet.
- D. Have you noticed changes in his abdominal size?
Correct Answer: C
Rationale: The usual diet is less directly related to diagnosing intussusception compared to symptoms like pain, vomiting, or abdominal changes.
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The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?
- A. Roast beef sandwich, potato chips, pickle spear, iced tea
- B. Split pea soup, mashed potatoes, pudding, milk
- C. Tomato soup, cheese toast, Jello, coffee
- D. Hamburger, baked beans, fruit cup, iced tea
Correct Answer: B
Rationale: Soft foods like split pea soup, mashed potatoes, and pudding are easier to swallow for a client with a facial stroke, reducing the risk of aspiration.
The nurse administers a dose of acetaminophen to the wrong client. Which of the following actions is the most appropriate after notifying the physician?
- A. Notify her supervisor and complete an incident report.
- B. Ask the physician for an order of acetaminophen to cover the inadvertent administration.
- C. Take no further action because acetaminophen is relatively benign.
- D. Document in the client's record that an error in drug administration occurred.
Correct Answer: A
Rationale: Medication errors require notifying the supervisor and completing an incident report (A) to ensure proper follow-up and system improvements. Retroactively obtaining an order (B) is unethical, assuming acetaminophen is benign (C) is unsafe, and documenting the error in the client's record (D) is inappropriate.
Which client is at the greatest risk of developing colon cancer?
- A. a 83-year-old Hispanic female with a past history of cholecystectomy
- B. a 62-year-old African American male with a past history of diabetes
- C. a 70-year-old Caucasian male with a past history of cancer treated with chemotherapy
- D. a 42-year-old Asian female who follows a high-fiber diet
Correct Answer: C
Rationale: Previous cancer history, especially treated with chemotherapy, increases colon cancer risk due to potential genetic or environmental factors. Age over 50 also elevates risk.
The physician has ordered an infusion of Osmitrol (mannitol) for a client with increased intracranial pressure. Which finding indicates the direct effectiveness of the drug?
- A. Increased pulse rate
- B. Increased urinary output
- C. Decreased diastolic blood pressure
- D. Increased pupil size
Correct Answer: B
Rationale: Mannitol is an osmotic diuretic that reduces intracranial pressure by increasing urinary output, drawing fluid out of the brain tissue.
The nurse is taking the blood pressure of the obese client. If the blood pressure cuff is too small, the results will be:
- A. A false elevation
- B. A false low reading
- C. A blood pressure reading that is correct
- D. A subnormal finding
Correct Answer: A
Rationale: A blood pressure cuff that is too small will result in a false elevation of the blood pressure reading due to increased pressure on the arm.