Nokea
A client diagnosed with chronic depression is maintained on tranylcypromine (Parnate). An important nursing intervention is to teach the client to avoid which of the following foods?
- A. Wine, beer, cheese, liver and chocolate
- B. Wine, citrus fruits, yogurt and broccoli
- C. Beer, cheese, beef and carrots
- D. Wine, apples, sour cream and beef steak
Correct Answer: A
Rationale: These foods are tyramine-rich and ingestion of these foods while taking monoamine oxidase inhibitors (MAOIs) can precipitate a life-threatening hypertensive crisis.
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A woman is in the clinic complaining of urinary frequency, urgency, and pain on urination. Orders include a urine for culture and administration of sulfisoxazole (Gantrisin) and phenazopyridine (Pyridium.) Which action should the nurse take first?
- A. Obtain a clean catch urine from the client.
- B. Ask the client if she is allergic to sulfa drugs.
- C. Administer the sulfisoxazole (Gantrisin).
- D. Administer the phenazopyridine (Pyridium).
Correct Answer: B
Rationale: Checking for sulfa allergies is critical before administering sulfisoxazole, as allergies can cause severe reactions, prioritizing safety.
The nurse is assessing cranial nerve XI. The nurse should:
- A. open a vial of cloves and ask the client to identify the scent.
- B. shine a flashlight in the client's eyes and observe the pupils.
- C. ask the client to shrug his shoulders.
- D. use the Snellen chart and have the client identify letters.
Correct Answer: C
Rationale: Cranial nerve XI (spinal accessory) controls neck and shoulder muscles; shoulder shrugging tests its function, unlike scent (I), pupil response (III), or vision (II).
The nurse is preparing to care for a client who has returned to the surgical nursing unit following a radical neck dissection.
- A. What is the most appropriate nursing action for a client post-radical neck dissection with a tracheostomy?
- B. Suction the tracheostomy every four hours.
- C. Provide tracheostomy care every 12 hours.
- D. Assess the tracheostomy for patency every shift.
- E. Monitor the tracheostomy site for bleeding or swelling.
Correct Answer: D
Rationale: Following a radical neck dissection, monitoring the tracheostomy site for bleeding or swelling is critical due to the risk of hematoma or airway obstruction, which can be life-threatening. Suctioning and care are important but follow a schedule or as needed, and patency assessment is less urgent than monitoring for surgical complications.
When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility?
- A. Digestive problems
- B. Amenorrhea
- C. Electrolyte imbalance
- D. Blood disorders
Correct Answer: B
Rationale: Amenorrhea. Changes in reproductive hormones and in thyroid hormones can cause absence of menstruation, called amenorrhea, which contributes to osteoporosis and bone fractures.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD).
- A. Which intervention should the nurse include in the care plan for a client with COPD?
- B. Encourage a high-protein, low-carbohydrate diet.
- C. Administer oxygen at 6 liters per minute via nasal cannula.
- D. Teach the client to use pursed-lip breathing.
- E. Place the client in a supine position to promote rest.
Correct Answer: C
Rationale: Pursed-lip breathing prolongs exhalation, reducing air trapping and improving oxygenation in COPD. High-protein diets are beneficial but secondary, high-flow oxygen risks CO2 retention, and supine positioning impairs breathing.