Nokea
A client has a new diagnosis of hypertension and is being taught about dietary management. Which of the following statements should be included by the healthcare provider?
- A. Increase your intake of sodium-rich foods.
- B. Decrease your intake of sodium-rich foods.
- C. Avoid foods that contain lactose.
- D. Increase your intake of dairy products.
Correct Answer: B
Rationale: The correct answer is B: 'Decrease your intake of sodium-rich foods.' When managing hypertension, reducing the intake of sodium-rich foods is essential. Excessive sodium can contribute to increased blood pressure, which is why limiting its consumption is crucial to prevent complications. Choices A, C, and D are incorrect. Increasing sodium intake would exacerbate hypertension, avoiding lactose is unrelated to managing hypertension, and increasing dairy product intake does not specifically address the issue of sodium intake in hypertension management.
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Which statement best describes the effects of immobility in children?
- A. Immobility prevents the progression of language and fine motor development
- B. Immobility in children has similar physical effects to those found in adults
- C. Children are more susceptible to the effects of immobility than are adults
- D. Children are likely to have prolonged immobility with subsequent complications
Correct Answer: B
Rationale: Children experience similar physical immobility effects as adults, like atrophy and demineralization.
During a Romberg test, the nurse asks the patient to assume which position?
- A. Sitting
- B. Standing
- C. Genupectoral
- D. Trendelenburg
Correct Answer: B
Rationale: The Romberg test assesses balance while standing with eyes open and closed.
Neonate of diabetic mother is at risk for all of the following except:
- A. Hypoglycemia
- B. Hypocalcemia
- C. Hyperglycemia
- D. Hyperbilirubinemia
Correct Answer: C
Rationale: Neonates of diabetic mothers (NDM) face metabolic challenges due to maternal hyperglycemia. Hypoglycemia (choice A) occurs because fetal hyperinsulinemia, triggered by high maternal glucose, persists after birth when glucose supply drops. Hypocalcemia (choice B) arises from delayed parathyroid hormone response, common in NDMs. Hyperglycemia (choice C) is less likely postnatally; it's a maternal issue, not a neonatal risk, as the infant's insulin levels typically normalize glucose after delivery. Hyperbilirubinemia (choice D) results from increased red blood cell breakdown, often linked to polycythemia in NDMs. Choice C is correct because hyperglycemia is not a typical risk after birth; instead, hypoglycemia dominates due to insulin excess. Nurses must monitor blood glucose closely in the first hours, provide calcium if needed, and watch for jaundice, ensuring timely management of these interconnected risks to prevent seizures, bone issues, or kernicterus.
Which of the following statement is TRUE about the Patient's Bill of Rights?
- A. Only applies to emergencies
- B. Ensures respectful care
- C. Excludes information rights
- D. All of the above
Correct Answer: B
Rationale: The Patient's Bill of Rights ensures respectful care (B), per ANA e.g., dignity, info access. Not emergency-only (A), includes info (C), not all (D) broad scope. B truly defines its protective role for patients like Mr. Gary, making it correct.
The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?
- A. Suctioning is required frequently.
- B. Aspiration of gastric contents occurs when suctioning.
- C. The client's skin and mucous membranes are light pink.
- D. Excessive secretions are suctioned from a tracheostomy.
Correct Answer: B
Rationale: Tracheoesophageal fistula (TEF), a rare tracheostomy complication, involves an abnormal connection between trachea and esophagus. Aspiration of gastric contents during suctioning (B) is a definitive sign, indicating esophageal leakage into the airway. Frequent suctioning (A) or excessive secretions (D) are nonspecific. Pink skin (C) reflects good oxygenation, not TEF. B is correct. Rationale: TEF allows gastric contents to enter the trachea, detected during suctioning, requiring urgent intervention like tube adjustment or surgery, distinct from routine secretion issues, per critical care nursing.