Nokea
A client with a prescription for a clear liquid diet is receiving teaching about food choices from a nurse. Which of the following selections by the client indicates an understanding of the teaching?
- A. Gelatin
- B. Whole milk
- C. Cream soups
- D. Orange juice
Correct Answer: A
Rationale: The correct answer is A: Gelatin. Gelatin is suitable for a clear liquid diet because it is transparent and free of solid particles. Clear liquid diets are designed to be easily digested and leave minimal residue in the gastrointestinal tract. Choices B, C, and D are not appropriate for a clear liquid diet. Whole milk, cream soups, and orange juice contain solid particles or pulp, which are not allowed on a clear liquid diet. Whole milk and cream soups are not clear liquids as they contain milk solids and vegetable particles respectively. Orange juice contains pulp, which is not part of a clear liquid diet. It is important for clients to follow dietary restrictions to achieve the intended therapeutic outcomes.
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A guardian reports that a 4-year-old child is waking up with nightmares. Which of the following interventions should the nurse suggest?
- A. Offer the child a large snack before bedtime.
- B. Allow the child to watch an extra 30 minutes of TV in the evening.
- C. Have the child go to bed at a consistent time every day.
- D. Increase physical activity before bedtime.
Correct Answer: C
Rationale: The correct answer is to have the child go to bed at a consistent time every day. Consistent bedtime routines can help reduce nightmares by providing the child with a sense of security and stability. Offering a large snack before bedtime or allowing extra TV time may disrupt sleep patterns and lead to nightmares. Increasing physical activity before bedtime could have the opposite effect and make it harder for the child to fall asleep.
A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first?
- A. Assessment
- B. History of present illness
- C. Plan of care
- D. Admission date and time
Correct Answer: D
Rationale: When admitting a client to a medical-surgical unit, documenting the admission date and time is crucial as it establishes the timeline for the client's care. This information ensures accurate tracking of interventions and facilitates communication among the healthcare team. While assessment, history of present illness, and plan of care are important components of the admission process, documenting the admission date and time takes priority to establish a baseline for care delivery. Without the admission date and time, the continuity of care and coordination among healthcare providers may be compromised.
A community health nurse is caring for a group of families. The nurse should identify which of the following families is experiencing a maturational loss?
- A. A family whose only child recently died due to cancer.
- B. A family whose head of household lost her job.
- C. A family whose house was destroyed in a fire.
- D. A family whose oldest child is moving away for college.
Correct Answer: D
Rationale: The correct answer is D because maturational loss is related to developmental changes, such as children leaving for college. This type of loss is tied to the normal life transitions of individuals and can lead to feelings of grief and adjustment. Choices A, B, and C represent different types of losses. Choice A involves a traumatic loss of a child due to illness, choice B involves a financial loss impacting the head of household's job, and choice C involves a material loss due to a fire incident. While these losses are significant, they do not specifically relate to maturational loss, which is associated with expected life stage transitions.
A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition?
- A. Dyspnea
- B. Heart murmur
- C. Macular rash
- D. Hemorrhage
Correct Answer: B
Rationale: A new or changed heart murmur is a common sign of valve involvement in infective endocarditis, indicating a complication such as valve damage or regurgitation. Dyspnea is more commonly associated with respiratory or cardiac conditions not directly related to infective endocarditis. A macular rash is not a typical symptom of infective endocarditis, suggesting other conditions like infectious diseases. Hemorrhage is not a direct complication of infective endocarditis but may occur due to factors such as anticoagulant therapy or underlying bleeding disorders.
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management?
- A. "It might help me to listen to music while I'm lying in bed."
- B. "I will use the pain medication as prescribed to manage the pain."
- C. "I will request a different type of pain medication if the pain persists."
- D. "I will ask for a physical therapist to help with the pain."
Correct Answer: A
Rationale: The correct answer is A. Listening to music is a non-pharmacological method to help manage mild pain, reflecting an understanding of pain management strategies. It shows the client's grasp of non-pharmacological pain management techniques taught preoperatively. Choice B, while important, only addresses pharmacological pain management, omitting other strategies discussed in preoperative teaching. Choice C jumps to changing medications without considering non-pharmacological methods first, indicating a narrow approach to pain management. Choice D involves a physical therapist, which is not directly related to the pain management strategies typically discussed in preoperative teaching.