Nokea
A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as:
- A. plantar fasciitis.
- B. hallux valgus.
- C. hammertoe.
- D. Morton's neuroma.
Correct Answer: D
Rationale: Morton's neuroma is a small mass or tumor in a digital nerve of the foot. Hallux valgus is referred to in lay terms as a bunion. Hammertoe is where one toe is cocked up over another toe. Plantar fasciitis is an inflammation of, or pain in, the arch of the foot.
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The nurse explains to a client who underwent gastric resection that which of the following meals is most likely to cause rapid emptying of the stomach?
- A. a high-protein meal
- B. a high-fat meal
- C. a large meal regardless of nutrient content
- D. a high-carbohydrate meal
Correct Answer: D
Rationale: Meals that are high in carbohydrates promote rapid gastric emptying. The other options are associated with decreased emptying time.
The client with a new colostomy asks how to deal with gas coming from the stoma. To respond to the client's concern, the nurse should ask the client to take which action? Select all that apply.
- A. Describe the dietary intake, including types of foods.
- B. Include cruciferous vegetables in the diet daily.
- C. Decrease fluid intake to 1200 mL per 24 hours.
- D. Prick the colostomy stoma pouch with a pin.
- E. Limit intake of gas-producing carbonated sodas.
- F. In the bathroom, open the pouch clamp to release gas.
Correct Answer: A,E,F
Rationale: A: Assessing diet identifies gas-producing foods. E: Limiting carbonated drinks reduces gas. F: Releasing gas in a bathroom controls odor. B: Cruciferous vegetables increase gas. C: Reduced fluid risks dehydration. D: Pricking the pouch causes leaks and odor.
A nurse is working in a pediatric clinic and a mother brings in her 13 month old child who has Down Syndrome. The mother reports, 'My child's muscles feel weak and he isn't moving well. My RN friend checked his reflexes and she said they are diminished.' Which of the following actions should the nurse take first?
- A. Contact the physician immediately
- B. Have the patient go to X-ray for a c-spine work-up.
- C. Start an IV on the patient
- D. Position the child's neck in a neutral position
Correct Answer: D
Rationale: An atlanto-axial dislocation may have occurred, common in Down Syndrome. Positioning the child's neck in a neutral c-spine posture is the first step to prevent further injury, followed by contacting the doctor.
Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?
- A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m.
- B. taking a cool shower and drinking a hot cup of tea
- C. watching TV nightly until midnight
- D. getting a back rub and drinking a glass of warm milk
Correct Answer: D
Rationale: A back rub and warm milk promote relaxation and sleep. Vigorous exercise, cool showers, hot tea, and late TV watching are stimulating and disrupt sleep.
Which of the following is an appropriate nursing goal for a client at risk for nutritional problems?
- A. provide oxygen
- B. promote healthy nutritional practices
- C. treat complications of malnutrition
- D. increase weight
Correct Answer: B
Rationale: Promoting healthy nutritional practices is an appropriate nursing goal for a client at risk for nutritional problems. Choice A is incorrect because it is a nursing intervention, not a goal statement. Choice C is incorrect because it is a therapeutic treatment. Choice D is incorrect because weight gain is an appropriate goal only if the client is underweight.