Nokea
Which of the following statements by a client indicates an understanding of the teaching?
- A. I should take antibiotics when I have a virus.
- B. I can visit my nephew who has chickenpox 5 days after the sores have crusted.
- C. I should avoid cleaning my cat's litter box during pregnancy.
- D. I do not need to get the flu vaccine while I am pregnant.
Correct Answer: C
Rationale: The correct answer is C: "I should avoid cleaning my cat's litter box during pregnancy." This statement shows an understanding of the teaching because cleaning a cat's litter box can expose a pregnant person to toxoplasmosis, a harmful parasite that can cause complications during pregnancy. Avoiding this task is a precautionary measure recommended to protect the health of the mother and the unborn child.
Explanation of why other choices are incorrect:
A: "I should take antibiotics when I have a virus." - Antibiotics are not effective against viruses, so this statement shows a misunderstanding of when antibiotics should be used.
B: "I can visit my nephew who has chickenpox 5 days after the sores have crusted." - Chickenpox is highly contagious, so visiting someone with active chickenpox can put the pregnant person at risk.
D: "I do not need to get the flu vaccine while I am pregnant." - The flu vaccine is recommended during pregnancy to protect both the pregnant
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Which of the following food choices is appropriate for this client?
- A. Canned barley soup
- B. Potato pancakes.
- C. Wheat crackers
- D. White flour tortillas
Correct Answer: B
Rationale: The correct answer is B: Potato pancakes. This choice is appropriate as it is likely to be well-tolerated by the client. Potatoes are a good source of carbohydrates and can provide energy. Additionally, potato pancakes are easy to digest and can be a good option for someone with digestive issues. On the other hand, A, C, and D contain grains that may be harder to digest for some individuals, especially if they have digestive concerns. Canned barley soup (A) may also contain added preservatives and sodium, which may not be ideal for the client's condition. Wheat crackers (C) can be high in fiber and may be difficult to digest. White flour tortillas (D) are made from refined grains and may not provide the necessary nutrients for the client.
Which of the following manifestations indicates that the client might be experiencing hypoglycemia?
- A. Confusion
- B. Increased thirst
- C. Frequent urination
- D. Flushed skin
Correct Answer: A
Rationale: The correct answer is A: Confusion. Hypoglycemia is a condition characterized by low blood sugar levels, leading to symptoms like confusion due to the brain not receiving enough glucose for energy. Increased thirst and frequent urination are more indicative of hyperglycemia (high blood sugar levels). Flushed skin is not a common manifestation of hypoglycemia.
Which of the following instructions should the nurse include in the teaching?
- A. Take your temperature immediately after waking and before getting out of bed.
- B. Measure your temperature in the afternoon for the most accurate reading.
- C. A rise in body temperature of at least 2°F indicates ovulation has occurred.
- D. Use a standard digital thermometer for the most precise results.
Correct Answer: A
Rationale: The correct answer is A: Take your temperature immediately after waking and before getting out of bed. This instruction is part of basal body temperature monitoring for ovulation tracking. Body temperature is lowest upon waking and increases after ovulation, so taking the temperature before getting out of bed provides the most accurate baseline measurement. Choice B is incorrect because afternoon temperatures can fluctuate due to various factors. Choice C is incorrect as a rise of at least 0.4°F, not 2°F, indicates ovulation. Choice D is incorrect because a basal body temperature thermometer is more appropriate for this purpose than a standard digital thermometer.
Which of the following findings should the nurse identify as the priority?
- A. Xerostomia
- B. Client reports a pain level of 6 on a scale from 0 to 10
- C. Excoriation of the skin on the neck and chest
- D. Dysphagia
Correct Answer: D
Rationale: The correct answer is D: Dysphagia. Dysphagia poses the highest risk of aspiration, malnutrition, and dehydration. Priority is given to life-threatening or potentially life-threatening issues. Xerostomia (A) is uncomfortable but not immediately life-threatening. Pain level (B) can be managed with medication. Excoriation of the skin (C) can be treated topically.
Which of the following guidelines should the nurse include?
- A. Document the client's condition every 15 minutes.
- B. Attach the restraint straps to the side rails of the bed.
- C. Use a square knot to secure the restraint.
- D. Ensure there is at least a 2-inch gap between the restraint and the client's body.
Correct Answer: A
Rationale: The correct answer is A: Document the client's condition every 15 minutes. This guideline is crucial for monitoring the client's status, detecting any changes promptly, and ensuring their safety. Documenting every 15 minutes allows for timely intervention and assessment.
Choice B is incorrect because attaching restraint straps to the side rails can lead to entrapment and harm.
Choice C is incorrect as a square knot is not recommended for securing restraints due to the risk of difficulty in quick release during emergencies.
Choice D is incorrect as a 2-inch gap between the restraint and the client's body can increase the risk of injury or self-removal.