Nokea
A client with a history of phenylketonuria (PKU) is seen in the local family planning clinic. While completing the intake history, the nurse provides information for a healthy pregnancy. Which statement indicates that the client needs further teaching?
- A. I can use use artificial sweeteners to keep me from gaining too much weight when I get pregnant.
- B. I need to go back on a low-phenylalanine diet before I get pregnant.
- C. Fresh fruits and raw vegetables will make good between-meal snacks for me.
- D. My baby could be mentally retarded if I don't stick to a diet eliminating phenylalanine.
Correct Answer: A
Rationale: Artificial sweeteners like aspartame contain phenylalanine, which is harmful in PKU, so the client's statement indicates a need for further teaching.
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The nurse is teaching a client with a new diagnosis of migraine headaches about trigger avoidance. Which of the following should the client avoid?
- A. Regular exercise.
- B. Aged cheeses.
- C. Fresh fruits.
- D. Daily meditation.
Correct Answer: B
Rationale: aged cheeses contain tyramine, a common migraine trigger
The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:
- A. Place tape on the child's perianal area before putting the child to bed
- B. Scrape the skin with a piece of cardboard and bring it to the clinic
- C. Obtain a stool specimen in the afternoon
- D. Bring a hair sample to the clinic for evaluation
Correct Answer: A
Rationale: The tape test, applied to the perianal area at night or early morning, is the standard method to collect pinworm eggs.
Which of the following best describes the language of a 24-month-old?
- A. Doesn't understand yes and no
- B. Understands the meaning of words
- C. Able to verbalize needs
- D. Asks 'why?' to most statements
Correct Answer: C
Rationale: A 24-month-old can verbalize needs using simple words or phrases, reflecting their developing language skills.
Which would be included in the nursing care plan of a client experiencing severe delirium tremens?
- A. Placing the client in a darkened room
- B. Keeping the closet and bathroom doors closed
- C. Administering a diuretic to decrease fluid excess
- D. Checking vital signs every 8 hours
Correct Answer: B
Rationale: Keeping closet and bathroom doors closed minimizes visual stimuli that could exacerbate hallucinations or confusion in delirium tremens, promoting a safe environment.
The nurse is performing discharge teaching to a client newly diagnosed with hypertension and high cholesterol. Which statement by the client indicates that the nurse's teaching was effective?
- A. I need to buy canned foods that are low in sodium.
- B. I can substitute lean sirloin for my homemade fried chicken.
- C. I will take a can of soup to work for lunch instead of eating a burger.
- D. Frozen dinners are better for me than eating in the cafeteria at work.
Correct Answer: B
Rationale: Substituting lean sirloin for fried chicken reduces fat and cholesterol. Canned foods, soups, and frozen dinners are often high in sodium, unsuitable for hypertension.