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A client is taught about healthy dietary measures and the MyPlate food plan. How many of his grains should be whole grains according to the MyPlate food plan?
- A. One-quarter
- B. One-third
- C. One-half
- D. Two-thirds
Correct Answer: C
Rationale: The correct answer is 'One-half.' According to the MyPlate food plan, at least half of the grains consumed daily should be whole grains. This ensures a well-balanced and healthy diet. Choices A, B, and D are incorrect because they do not align with the dietary recommendation provided by the MyPlate food plan. One-quarter, one-third, and two-thirds do not represent the appropriate proportion of whole grains as advised by the plan, which emphasizes the importance of including a significant portion of whole grains in one's diet.
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A nurse preparing to assist with data collection of the abdomen asks the client to void and then assists the client into a supine position. Which primary finding does the nurse expect to note on percussing all four quadrants of the abdominal cavity?
- A. Dullness
- B. Tympany
- C. Borborygmus
- D. Hyperresonance
Correct Answer: B
Rationale: The nurse expects to primarily note tympany when percussing the abdomen. Tympany should predominate because air in the intestines rises to the surface when the client is in a supine position. Dullness is usually heard over a distended bladder, adipose tissue, fluid, or a mass. Borborygmus, which refers to hyperperistalsis, is typically heard on auscultation, not percussion. Hyperresonance is present with gaseous distention, not the typical finding when percussing all four quadrants of the abdomen.
While taking the vital signs of a pregnant client admitted to the labor unit, a nurse notes a temperature of 100.6°F, pulse rate of 100 beats/min, and respirations of 24 breaths/min. What is the most appropriate nursing action based on these findings?
- A. Notify the registered nurse of the findings.
- B. Document the findings in the client's medical record.
- C. Recheck the vital signs in 1 hour.
- D. Continue collecting subjective and objective data.
Correct Answer: A
Rationale: The correct answer is to notify the registered nurse of the findings. In a pregnant client, the normal temperature range is 98°F to 99.6°F, with a pulse rate of 60 to 90 beats/min and respirations of 12 to 20 breaths/min. A temperature of 100.4°F or higher, along with an increased pulse rate and faster respirations, suggests a possible infection. Immediate notification of the registered nurse is crucial for further evaluation and intervention. While documenting the findings is essential, the priority lies in promptly escalating abnormal vital signs for assessment and management. Rechecking vital signs in 1 hour may delay necessary interventions for a deteriorating condition. Continuing to collect data is relevant but should not delay informing the registered nurse when abnormal vital signs are present.
While assessing a client’s skin, the nurse notes the presence of several large red-blue and purple areas on the client’s body that do not blanch when pressure is applied. The nurse documents this finding using which term?
- A. Psoriasis
- B. Anasarca
- C. Petechiae
- D. Ecchymosis
Correct Answer: D
Rationale: Ecchymosis refers to a large patch of capillary bleeding into the tissues, commonly known as a bruise. The color of such an area changes from red-blue or purple to green, yellow, and brown before the area disappears. Pressure on the area will not cause it to blanch. Psoriasis is characterized by scaly erythematous patches with silvery scales on top, usually found on specific areas like the scalp, elbows, knees, low back, and anogenital area. Anasarca is bilateral or generalized edema, indicating a central problem like congestive heart failure or kidney failure. Petechiae are tiny purple or red spots resulting from tiny hemorrhages within the dermal and subdermal areas. Therefore, in this case, the correct term to document the described finding is Ecchymosis.
A healthcare professional reviewing a client's record notes documentation that the client has melena. How does the healthcare professional detect the presence of melena?
- A. By checking the client's urine for blood
- B. By checking the client's stool for blood
- C. By checking the client's urine for a decrease in output
- D. By checking the client's bowel movements for diarrhea
Correct Answer: B
Rationale: Melena' is the term used to describe abnormal black tarry stool that has a distinctive odor and contains digested blood. It usually results from bleeding in the upper gastrointestinal tract and is often a sign of peptic ulcer disease or small bowel disease. The presence of melena is detected by checking the client's stool for blood. Blood in the client's urine, decreased urine output, and diarrhea are not associated with the assessment for melena.
A nurse is preparing to assess a client for the presence of the Tinel sign. Which action does the nurse take to elicit this sign?
- A. Testing for the strength of each muscle joint
- B. Percussing at the location of the median nerve
- C. Checking for repetitive movements in the joints
- D. Asking the client to flex the wrist 90 degrees while holding the hands back to back
Correct Answer: B
Rationale: The Tinel sign is elicited by percussing at the location of the median nerve at the wrist. In carpal tunnel syndrome, this test can produce burning and tingling along the nerve's distribution. Choices A, C, and D are incorrect. Testing for the strength of each muscle joint and checking for repetitive movements in the joints involve different assessments unrelated to the Tinel sign. Asking the client to flex the wrist 90 degrees while holding the hands back to back is associated with the Phalen test, which is another evaluation for carpal tunnel syndrome.