Nokea
A 72-year-old client with a new colostomy is being evaluated at the clinic today for constipation. When discussing diet with the client, the nurse recognizes that which one of the following foods most likely caused this problem?
- A. Fried chicken
- B. Eggs
- C. Tapioca
- D. Cabbage
Correct Answer: C
Rationale: Fried, greasy food, such as fried chicken, will produce diarrhealike stools in individuals with all types of GI ostomies. Eggs will cause odor-producing stools in individuals with all types of GI ostomies. Tapioca and rice products will cause constipation in individuals with all types of GI ostomies. Cabbage will cause odor-producing and flatus-producing stools in individuals with all types of GI ostomies.
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The nurse is caring for a client with a history of psoriasis. The nurse should expect the client to have:
- A. Scaly plaques
- B. Joint swelling
- C. Fever
- D. Chest pain
Correct Answer: A
Rationale: Psoriasis causes scaly, silvery plaques due to rapid skin cell turnover, a hallmark symptom.
Goal setting for a client with Meniere's disease should include which of the following?
- A. Frequent ambulation
- B. Prevention of a fall injury
- C. Consumption of three meals per day
- D. Prevention of infection
Correct Answer: B
Rationale: Although not contraindicated, initially ambulation may be difficult because of vertigo and is recommended only with assistance. Vertigo resulting in balance problems is one of the most common manifestations of Meniere's disease. Adequate nutrition is important, but the emphasis in Meniere's disease is not the number of meals per day but a decrease in intake of sodium. Infection is not an anticipated problem.
The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
- A. Teaching the client to report a nosebleed
- B. Instructing the client to maintain strict bed rest
- C. Telling the client to notify the doctor of pedal edema
- D. Advising the client to avoid sodium sources in the diet
Correct Answer: A
Rationale: Nosebleeds in preeclampsia may indicate severe hypertension or coagulopathy, requiring immediate reporting. Pedal edema is common, bed rest is not always needed, and sodium restriction is secondary.
The nurse is caring for a client with a diagnosis of gestational hypertension. Which complication is most likely to occur?
- A. Preeclampsia
- B. Preterm labor
- C. Fetal macrosomia
- D. All of the above
Correct Answer: A
Rationale: Gestational hypertension can progress to preeclampsia characterized by proteinuria and other systemic symptoms and is the most likely complication. Preterm labor and macrosomia are less directly related.
A client with a history of hypertension is receiving Aldactone (spironolactone). The nurse should teach the client to avoid:
- A. Potassium-rich foods
- B. Calcium supplements
- C. High-fiber foods
- D. Iron supplements
Correct Answer: A
Rationale: Spironolactone is a potassium-sparing diuretic, and consuming potassium-rich foods can lead to hyperkalemia. Calcium, fiber, and iron supplements are not contraindicated.