Nokea
A client is receiving teaching about a high-fiber diet to manage constipation. Which statement indicates the best choice for a high-fiber diet?
- A. Eating one medium apple is a good snack option.
- B. Selecting a ½ cup of sweet potatoes for starch is a great choice.
- C. Choosing a ½ cup of bran cereal for breakfast is ideal.
- D. Opting for 1 ounce of almonds when hungry midday is recommended.
Correct Answer: C
Rationale: The correct answer is C because bran cereal is a high-fiber food that can effectively alleviate constipation by promoting regular bowel movements. Option A, an apple, while a healthy snack, may not provide as much fiber as bran cereal. Option B, sweet potatoes, are nutritious but may not be as high in fiber as bran cereal. Option D, almonds, are a good source of healthy fats and protein but do not provide as much fiber as bran cereal.
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During an assessment on a client in congestive heart failure, what is most likely to be revealed upon auscultation of the heart?
- A. S3 ventricular gallop
- B. Apical click
- C. Systolic murmur
- D. Split S2
Correct Answer: A
Rationale: The correct answer is A: S3 ventricular gallop. An S3 sound is a common finding in congestive heart failure due to fluid overload in the heart. It is associated with decreased ventricular compliance. Choices B, C, and D are incorrect. An apical click is not typically associated with congestive heart failure. A systolic murmur may be heard in conditions like mitral regurgitation but is not specific to congestive heart failure. A split S2 is associated with conditions like pulmonary hypertension, not congestive heart failure.
Which of these nursing assessments would be the highest priority for a client at risk for aspiration pneumonia?
- A. Assessing the client's level of consciousness
- B. Monitoring the client's oxygen saturation
- C. Checking the client's gag reflex before eating or drinking
- D. Monitoring the client's intake and output
Correct Answer: C
Rationale: Checking the client's gag reflex before eating or drinking is the highest priority for a client at risk for aspiration pneumonia. Aspiration pneumonia can occur when food, liquids, or saliva are inhaled into the lungs, leading to inflammation or infection. Checking the gag reflex helps prevent the aspiration of substances into the lungs. Assessing the client's level of consciousness (Choice A) is important but not as immediately critical as checking the gag reflex. Monitoring oxygen saturation (Choice B) is essential for respiratory assessment but does not directly prevent aspiration. Monitoring intake and output (Choice D) is important for overall client management but does not specifically address the risk of aspiration pneumonia.
A client is being treated for tuberculosis (TB). Which of these statements indicates the client understands the transmission of TB?
- A. I need to wear a mask when I go out in public to prevent spreading the infection.
- B. I need to take my medication as prescribed to prevent spreading the infection to others.
- C. I need to cover my mouth when I cough to prevent spreading the infection.
- D. I need to isolate myself from others until my treatment is complete to prevent spreading the infection.
Correct Answer: A
Rationale: The correct answer is A because wearing a mask in public can help prevent the spread of TB to others. Choice B is incorrect as taking medication as prescribed helps in treating the infection within the individual but does not directly prevent spreading it to others. Choice C is important for respiratory hygiene but may not be sufficient to prevent transmission. Choice D, isolation until treatment is complete, is crucial for preventing the spread but is not specifically about understanding transmission.
The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
- A. Place the client in the wheelchair for four hours each day
- B. Pad the bony prominences
- C. Reposition every two hours
- D. Massage reddened bony prominence
Correct Answer: C
Rationale: Repositioning every two hours is the most effective measure in preventing skin breakdown for a client with a CVA. This practice helps to relieve pressure on the skin, reducing the risk of pressure ulcers. Placing the client in a wheelchair for extended periods (Choice A) can increase pressure on specific areas, leading to skin breakdown. Padding bony prominences (Choice B) can provide some protection but may not address the root cause of pressure ulcers. Massaging reddened bony prominences (Choice D) can potentially worsen the condition by causing further damage to already compromised skin.
When introducing solid foods to an infant, what food should be recommended to be introduced first?
- A. Strained fruits
- B. Pureed meats
- C. Cooked egg whites
- D. Iron-fortified cereal
Correct Answer: D
Rationale: When introducing solid foods to infants, iron-fortified cereal is usually recommended as the first food due to its high nutritional value and the importance of iron for the baby's development. Strained fruits (choice A) are often introduced later due to their higher sugar content. Pureed meats (choice B) and cooked egg whites (choice C) are usually introduced after iron-fortified cereal to provide additional sources of protein and other nutrients.