Nokea
A 68-year-old woman comes to the outpatient clinic for a routine health screening. The nurse learns the client is a retired teacher who lives alone on a limited income. A history indicates the client drinks about 1,500 cc a day and her diet consists primarily of starches. It is MOST important for the nurse to encourage the client to
- A. increase her intake of protein.
- B. increase her intake of vitamins.
- C. reduce her caloric intake.
- D. reduce her fluid intake.
Correct Answer: A
Rationale: protein needed to slow down degeneration process of aging
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While planning care for an elderly client with dementia, which of the following should be a priority for the nurse?
- A. Encourage dependency with activities of daily living.
- B. Provide flexibility in schedules due to his confusion.
- C. Limit reminiscing due to poor memory.
- D. Speak slowly in a face-to-face position.
Correct Answer: D
Rationale: is most effective when communicating with an elderly client
The nurse is caring for a 74-year-old man with type I diabetes. The client is scheduled for cataract surgery under general anesthesia at 9 AM. The man usually receives 30 units of NPH and 10 units of regular insulin each morning at 7 AM. At 7 AM the morning of surgery, the nurse would expect to take which of the following actions?
- A. hold the morning dose of NPH and regular insulin and monitor the blood glucose.
- B. give half the morning dose of NPH insulin along with the regular insulin and monitor the blood glucose when the client returns from surgery.
- C. give the full dose of NPH and regular insulin and monitor the blood glucose every 2 to 4 hours.
- D. give the full dose of regular insulin but hold the NPH insulin and monitor the blood glucose until the client goes to surgery.
Correct Answer: A
Rationale: usually use sliding scale with regular insulin based on blood glucose readings
The nurse is teaching a client with a new diagnosis of heart failure about carvedilol (Coreg). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication with food.
- B. I should check my pulse before taking this medication.
- C. I should report dizziness to my doctor.
- D. I should stop this medication if I feel better.
Correct Answer: D
Rationale: Stopping carvedilol when feeling better is incorrect, as heart failure requires lifelong treatment to manage symptoms and prevent progression. Options A, B, and C are correct: food reduces GI upset, pulse monitoring detects bradycardia, and dizziness may indicate hypotension.
A client is admitted with a suspected pulmonary embolism. Which of the following diagnostic tests should the nurse anticipate being ordered?
- A. Chest X-ray.
- B. D-dimer blood test.
- C. Echocardiogram.
- D. Arterial blood gas analysis.
Correct Answer: B
Rationale: D-dimer is a specific test to detect blood clots, highly sensitive for pulmonary embolism
A child comes to the school nurse with a honey-colored crusted lesion below her right nostril. Which of the following actions should the nurse take FIRST?
- A. Remove the scab.
- B. Apply a wet cloth to the lesion.
- C. Notify the child's parents.
- D. Contact the health department.
Correct Answer: C
Rationale: describes impetigo, highly infectious superficial bacterial infection; notify parents so they can contact the physician