Nokea
A client with chronic renal failure is experiencing central nervous system changes caused by uremic toxins. Which nursing intervention would be most appropriate for addressing the changes?
- A. Allow the client to grieve for body image changes.
- B. Restrict foods that are high in potassium.
- C. Restrict fluid intake to 1,000 mL/day.
- D. Assess the client's mental status regularly.
Correct Answer: D
Rationale: Regularly assessing mental status monitors uremic encephalopathy progression, guiding timely interventions in chronic renal failure.
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The nurse calls the primary health care provider to express concerns about a chemotherapeutic medication dose prescribed by the primary health care provider being too high. The primary health care provider office informs the nurse that the primary health care provider has left town and will not be available for several days. What action should the nurse take next to assure client safety?
- A. Reschedule the client's chemotherapy until the next week.
- B. Withhold giving the medication until the primary health care provider's partner makes rounds.
- C. Telephone the answering service and confer with the on-call primary health care provider.
- D. Confer with the pharmacist, who agrees the dose is too high, and then reduces the dose accordingly.
Correct Answer: C
Rationale: If the nurse believes a primary health care provider's prescription to be in error, the nurse must clarify the dosage with the client's primary health care provider or the primary health care provider's substitute before administering the medication. Rescheduling the client's chemotherapy is incorrect. Chemotherapy must be administered on a specific schedule for maximum effect with minimum adverse effects. Additionally, only a prescriber can withhold or reschedule chemotherapy. Withholding the medication until the partner makes rounds is incorrect. Chemotherapy agents must be administered in the proper combinations or sequence in order to be effective. Checking with the pharmacist can assist the nurse in determining whether the dose prescribed is incorrect, but the nurse or pharmacist cannot alter the dose without a revised prescription from a licensed primary health care provider with prescriptive authority.
A 16-year-old Hispanic client at 10 weeks' gestation has been diagnosed with mild iron deficiency anemia. The client tells the nurse that she doesn't like to eat much meat. Which of the following foods should the nurse suggest to provide the client with the greatest amount of iron in her diet?
- A. 1 cup of lentils
- B. 1 cup of sunflower seeds
- C. 1/2oz of hard cheese
- D. 2 poached eggs
Correct Answer: A
Rationale: Lentils are a rich plant-based source of iron, providing significantly more iron per serving than sunflower seeds, cheese, or eggs, making them ideal for a client avoiding meat.
The nurse is teaching a client with a new diagnosis of asthma about the use of a peak flow meter. Which of the following instructions is most important?
- A. Use the meter once a week.
- B. Record the highest of three readings.
- C. Clean the meter with soap daily.
- D. Use the meter only during an asthma attack.
Correct Answer: B
Rationale: Recording the highest of three readings provides an accurate measure of peak expiratory flow to monitor asthma control.
When a client of Mexican American descent tells the nurse that she treated her infection by drinking milk, the nurse interprets the client's remark as:
- A. Confusion from fever
- B. Use of the first disease concept
- C. Use of milk as a laxative
- D. The need for a dietitian to assist her with meal planning
Correct Answer: B
Rationale: In Mexican American culture, milk may be used as a traditional remedy for certain conditions, reflecting the ‘hot-cold' disease concept. It's not necessarily confusion, a laxative, or a dietary issue.
The nurse assesses for euphoria in a client with multiple sclerosis, looking for which of the following characteristic clinical manifestations?
- A. Inappropriate laughter.
- B. An exaggerated sense of well-being.
- C. Slurring of words when excited.
- D. Visual hallucinations.
Correct Answer: B
Rationale: Euphoria in multiple sclerosis is characterized by an exaggerated sense of well-being, often disproportionate to the client's condition.