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A client with cirrhosis is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of sodium-rich foods.
- B. I should decrease my intake of sodium-rich foods.
- C. I should increase my intake of potassium-rich foods.
- D. I should decrease my intake of potassium-rich foods.
Correct Answer: B
Rationale: The correct answer is B. In cirrhosis, decreasing the intake of sodium-rich foods is essential to manage fluid retention and symptoms. Excessive sodium intake can worsen fluid accumulation and lead to complications such as ascites. Therefore, advising the client to decrease sodium-rich foods demonstrates an understanding of the dietary management necessary for cirrhosis. Choices A, C, and D are incorrect because increasing sodium-rich foods can exacerbate fluid retention and complications in cirrhosis, increasing potassium-rich foods is not the primary focus of dietary management in cirrhosis, and decreasing potassium-rich foods is not a key recommendation for managing cirrhosis-related dietary issues.
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A healthcare professional is preparing to administer a cleansing enema to a client. Which of the following actions should the healthcare professional plan to take?
- A. Insert the rectal tube 15.2 cm (6 inches) into the client's rectum
- B. Wear clean gloves before inserting the tubing
- C. Position the client on their left side
- D. Hold the solution bag 91 cm (36 inches) above the client's rectum
Correct Answer: C
Rationale: Positioning the client on their left side is crucial when administering an enema as it helps facilitate the flow of the solution into the sigmoid and descending colon. This position allows gravity to assist in the process. Placing the client on the left side is a standard practice to promote optimal outcomes during the procedure. Choices A, B, and D are incorrect. Choice A provides a specific measurement for the insertion depth of the rectal tube, which is not typically necessary to include in the plan of action. Choice B is essential but not specific to enema administration. Choice D mentions holding the solution bag without specifying the correct height, which should typically be around 18-24 inches above the rectum for a cleansing enema.
Which are goals of nursing theory?
- A. Provide knowledge and a rationale for client interventions
- B. Provide a rationale for appropriate nursing actions in a given situation
- C. Identify and define concepts that are important to nursing
- D. Provide a definition for nursing
Correct Answer: A
Rationale: Nursing theory serves as a foundational framework, guiding practice with clear goals. It provides knowledge and a rationale for client interventions, explaining why specific actions like wound care techniques benefit patients, rooted in conceptual understanding. It offers a rationale for appropriate nursing actions, ensuring responses to situations, such as pain management, are logical and effective. Identifying and defining concepts important to nursing like health or caring clarifies the discipline's focus, fostering consistency. Increasing the nursing body of knowledge expands its intellectual base through theoretical development. However, it doesn't provide a single definition for nursing, instead directing it toward a common purpose across diverse interpretations. These goals unify nursing, bridging theory to practice, and equip nurses to deliver informed, purposeful care that adapts to client needs and evolves with new insights.
During an admission interview, a nurse is assessing a client's personal identity. Which of the following questions should the nurse ask?
- A. What is your marital status?
- B. How would you describe yourself?
- C. Are you employed?
- D. Do you have any children?
Correct Answer: B
Rationale: When assessing personal identity, it is important to ask questions that prompt clients to describe themselves. Question B, 'How would you describe yourself?' is the most appropriate as it allows the client to share their own perceptions and characteristics, aiding in understanding their personal identity. Choices A, C, and D are more focused on specific personal details such as marital status, employment status, and parental status, which do not directly contribute to understanding personal identity.
Which of the following statement best describe subjective data?
- A. Measurable by the nurse
- B. Reported by the client
- C. Always accurate
- D. A physical finding
Correct Answer: B
Rationale: Subjective data is reported by the client (B), per assessment e.g., pain level. Not measurable (A), not always accurate (C), not physical (D) client-based. B best defines subjective's source, making it correct.
During an abdominal assessment, what is the correct sequence of steps for a healthcare provider to follow?
- A. Inspection, percussion, palpation, auscultation
- B. Percussion, auscultation, inspection, palpation
- C. Auscultation, palpation, inspection, percussion
- D. Inspection, auscultation, percussion, palpation
Correct Answer: D
Rationale: During an abdominal assessment, the correct sequence of steps is inspection, auscultation, percussion, and palpation. This sequence is followed to prevent altering bowel sounds. Inspection allows for visual observation, followed by auscultation to listen for bowel sounds without causing disturbance, percussion to assess for tympany or dullness, and finally palpation to feel for any abnormalities or tenderness. Choice A is incorrect because palpation should come after percussion. Choice B is incorrect as auscultation should be performed after inspection. Choice C is incorrect because palpation should be the final step after percussion.