Nokea
A client with alcoholism has been instructed to increase his intake of thiamine. The nurse knows the client understands the instructions when he selects which food?
- A. Roast beef
- B. Broiled fish
- C. Baked chicken
- D. Sliced pork
Correct Answer: D
Rationale: Sliced pork is a rich source of thiamine (vitamin B1), which is critical for preventing Wernicke's encephalopathy in clients with alcoholism.
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A client is admitted with a diagnosis of pernicious anemia. Which of the following signs or symptoms would indicate that the client has been noncompliant with ordered B12 injections?
- A. Hyperactivity in the evening hours
- B. Weight gain of 5 pounds in 1 week
- C. Paresthesia of hands and feet
- D. Diarrhea stools several times a day
Correct Answer: C
Rationale: Pernicious anemia causes B12 deficiency, leading to neurological symptoms like paresthesia. Noncompliance with B12 injections would result in persistent or worsening paresthesia.
A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:
- A. Uses an electric blanket at night
- B. Dresses in extra layers of clothing
- C. Applies a heating pad to her feet
- D. Takes a hot bath morning and evening
Correct Answer: B
Rationale: Dressing in extra layers of clothing is a safe and effective way to manage cold intolerance in hypothyroidism, avoiding risks associated with electric blankets or heating pads.
A 20-year-old male has recently been diagnosed with schizophrenia. The nurse knows which of the following are classic signs and symptoms of this disorder? Select all that apply.
- A. social withdrawal
- B. agitation
- C. auditory hallucinations
- D. disorganized speech
- E. obsession with personal hygiene
Correct Answer: A,C,D
Rationale: Schizophrenia symptoms include social withdrawal, auditory hallucinations, and disorganized speech. Agitation may occur but is less specific, and obsession with hygiene is not typical.
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:
- A. Maternal hypoglycemia
- B. Fetal bradycardia
- C. Maternal hyperreflexia
- D. Fetal movement
Correct Answer: B
Rationale: Pitocin can cause uterine hyperstimulation, leading to fetal bradycardia, which requires close monitoring.
A client with vaginal cancer is being treated with a radioactive vaginal implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that:
- A. Overnight stays by family members is against hospital policy.
- B. There is no need for him to stay because staffing is adequate.
- C. His wife will rest much better knowing that he is at home.
- D. Visitation is limited to 30 minutes when the implant is in place.
Correct Answer: D
Rationale: Radiation safety protocols limit visitation to short periods (e.g., 30 minutes) to minimize exposure to radioactive implants.