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A client is admitted with a diagnosis of myocardial infarction (MI). Which intervention is a priority during the acute phase?
- A. Administer morphine for pain relief
- B. Encourage the client to perform isometric exercises
- C. Position the client flat in bed
- D. Restrict fluid intake
Correct Answer: A
Rationale: During the acute phase of a myocardial infarction (MI), the priority intervention is to administer morphine for pain relief. Morphine not only alleviates pain but also reduces myocardial oxygen demand, which is crucial in the management of MI. Encouraging the client to perform isometric exercises (choice B) can increase myocardial oxygen demand and should be avoided during the acute phase. Positioning the client flat in bed (choice C) may worsen symptoms by increasing venous return and workload on the heart. Restricting fluid intake (choice D) is not a priority intervention during the acute phase of MI; maintaining adequate hydration is important for organ perfusion.
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The client with newly diagnosed peptic ulcer disease (PUD) is being taught about lifestyle modifications. Which instruction should be included?
- A. Increase the intake of spicy foods
- B. Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs)
- C. Drink coffee in moderation
- D. Eat large meals at bedtime
Correct Answer: B
Rationale: The correct instruction to include when teaching a client with newly diagnosed PUD about lifestyle modifications is to avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs can exacerbate peptic ulcer disease by causing further irritation of the gastric mucosa. Increasing the intake of spicy foods (choice A) can aggravate the condition by irritating the stomach lining. Drinking coffee (choice C) can stimulate gastric acid secretion, which may worsen the symptoms of PUD. Eating large meals at bedtime (choice D) can also exacerbate PUD by increasing gastric acid production when the body is at rest, potentially leading to discomfort and symptoms.
A hospitalized toddler who is recovering from a sickle cell crisis holds a toy and says 'Mine'. According to Erikson's theory of psychosocial development, this child's behavior is a demonstration of which developmental stage?
- A. Autonomy vs. Shame and Doubt
- B. Industry vs. Inferiority
- C. Initiative vs. Guilt
- D. Trust vs. Mistrust
Correct Answer: A
Rationale: The correct answer is A: Autonomy vs. Shame and Doubt. In Erikson's theory, toddlers aged 1-3 years are in the Autonomy vs. Shame and Doubt stage. During this stage, children begin to assert their independence and control over their environment. The behavior of the hospitalized toddler holding a toy and saying 'Mine' demonstrates the child's developing sense of autonomy and ownership. Choices B, C, and D correspond to different stages in Erikson's theory: Industry vs. Inferiority (school-age children), Initiative vs. Guilt (preschoolers), and Trust vs. Mistrust (infants), respectively, which are not applicable to the behavior described.
The nurse is preparing a client for discharge following a myocardial infarction. What should the nurse prioritize in the discharge instructions?
- A. Warning signs of a potential heart attack
- B. Importance of medication adherence
- C. Follow-up appointment details
- D. All of the above
Correct Answer: D
Rationale: When preparing a client for discharge after a myocardial infarction, the nurse should prioritize providing comprehensive instructions. This includes educating the client about warning signs of a potential heart attack to recognize symptoms early, stressing the importance of medication adherence for optimal recovery and prevention of further cardiac events, and ensuring understanding of follow-up appointment details for ongoing monitoring and care. All these aspects are crucial in preventing complications and promoting the client's well-being. Therefore, selecting 'All of the above' as the correct answer is the most appropriate choice. Choices A, B, and C are all essential components of a holistic discharge plan for a client post-myocardial infarction.
What safety measure should be implemented when administering chemotherapy?
- A. Use protective gloves and gown
- B. Prepare the medication in a designated area
- C. Administer the medication at the appropriate rate
- D. Verify the two client identifiers
Correct Answer: A
Rationale: When administering chemotherapy, it is crucial to use protective gloves and a gown to protect against exposure to hazardous drugs that can be harmful through skin contact. Choice B is incorrect because chemotherapy medication should be prepared in a designated area to prevent contamination and ensure accurate preparation. Choice C is incorrect as chemotherapy should be administered at the appropriate rate to ensure patient safety and avoid adverse effects. Choice D is incorrect as verifying client identifiers is important for medication administration in general but not a specific safety measure related to chemotherapy administration.
A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu items should the nurse suggest? (Select all that apply.)
- A. Raisin bran muffins
- B. Bowl of oatmeal
- C. Cup of raspberries
- D. Scrambled eggs
Correct Answer: A
Rationale: A high-fiber diet is beneficial for managing hemorrhoids as it helps maintain bowel regularity. Raisin bran muffins are a good choice for breakfast as they are high in fiber. Oatmeal is also a high-fiber option that aids digestion and prevents constipation. Raspberries are rich in fiber and contribute to a high-fiber diet. Scrambled eggs, on the other hand, are not high in fiber and do not provide the necessary fiber content needed for managing hemorrhoids.