Nokea
A client with a new diagnosis of diverticulitis is being taught dietary management by a healthcare provider. Which of the following statements should the provider include in the teaching?
- A. You should increase your intake of high-fiber foods.
- B. You should avoid foods that contain lactose.
- C. You should decrease your intake of high-fiber foods.
- D. You should increase your intake of dairy products.
Correct Answer: A
Rationale: Increasing intake of high-fiber foods is essential in managing diverticulitis as it promotes regular bowel movements and prevents constipation, reducing the risk of complications and improving overall digestive health. Choice B is incorrect because lactose intolerance is different from diverticulitis and avoiding lactose is not a standard recommendation for diverticulitis. Choice C is incorrect as decreasing high-fiber foods would be counterproductive for managing diverticulitis. Choice D is wrong because increasing dairy products is not a primary dietary recommendation for diverticulitis management.
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A client's wife has been informed by the physician that her spouse has a permanent C2-C3 spinal injury, which has resulted in permanent quadriplegia. The wife states that she does not want the physician or nursing staff to tell the client about his injury. The client is awake, alert, and oriented when he asks his nurse to tell him what has happened. The nurse has conflicting emotions about how to handle the situation and is experiencing:
- A. autonomy.
- B. moral distress.
- C. moral doubt.
- D. moral courage.
Correct Answer: B
Rationale: The nurse's conflict between truth-telling and the wife's request is moral distress (B), feeling unable to act ethically. Autonomy (A) is patient rights. Doubt (C) is uncertainty. Courage (D) is acting despite fear. B is correct. Rationale: Moral distress arises from ethical dilemmas, common in nursing when values clash, per ethics frameworks, requiring resolution.
Which of the following behaviors by Nurse Jane Robles demonstrates that she understands well the elements of effecting charting?
- A. She signs her charting as follows: J.R
- B. She writes in the chart using a no. 2 pencils.
- C. She noted: appetite is good this afternoon.
- D. She signs on the medication sheet after administering the medication.
Correct Answer: D
Rationale: Effective charting requires accuracy, clarity, and accountability, adhering to legal and professional standards. Signing the medication sheet after administering medication, as Nurse Jane does, exemplifies this by confirming the intervention occurred, ensuring patient safety, and providing a verifiable record. This practice aligns with the 'Five Rights' of medication administration and reduces error risks, such as double-dosing. Conversely, signing as 'J.R.' lacks full identification (name and title), compromising accountability. Using a pencil risks erasure or alteration, undermining record integrity, as permanent ink is standard. Noting 'appetite is good' is subjective and lacks detail (e.g., meal percentage consumed), reducing its clinical value. Nurse Jane's action of signing post-medication administration reflects a strong grasp of charting's role in care continuity and safety, making it the best demonstration of effective documentation principles.
You partially darken a room and ask the client to look straight ahead. You use a penlight and, approaching from the side you shine the light, it constricts. You remove the light and then shine it on the same pupil again. You also observe the response of the other pupil. You would normally find the other pupil doing which of the following things?
- A. not make any change in size
- B. dilate in an oppositional response to the light
- C. first constrict, then dilate larger than the other pupil
- D. constrict in consensual response
Correct Answer: D
Rationale: The other pupil constricts consensually when light hits one, a normal reflex. No change, dilation, or mixed response indicates abnormality. Nurses test this for brain function.
Which of the following statement is TRUE about objective data?
- A. Reported by the client
- B. Observed by the nurse
- C. Always subjective
- D. All of the above
Correct Answer: B
Rationale: Objective data is observed by the nurse (B), per assessment e.g., rash. Not reported (A), not subjective (C), not all (D) measurable. B truly defines objective's basis, making it correct.
Which of the following statements best describes a wellness nursing diagnosis for an individual, family, or community?
- A. clinical judgment of transition to a higher level of wellness
- B. nursing judgment that in some area no pathology exists
- C. a judgment that in some area there is more wellness than illness
- D. statement of an area of family strength to use in interventions
Correct Answer: A
Rationale: A wellness nursing diagnosis best describes a clinical judgment of transitioning to a higher wellness level, focusing on enhancing health beyond mere absence of disease. Unlike pathology-based diagnoses, it identifies potential for growth like improving nutrition in a healthy client reflecting nursing's preventive role. Judging no pathology or more wellness than illness is narrower, missing the forward-looking aspect, while family strengths support interventions but aren't the diagnosis. This perspective encourages proactive care, aligning with wellness models to elevate client health.