A client with gout 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 purine-rich foods.
- B. I should decrease my intake of purine-rich foods.
- C. I should increase my intake of sodium-rich foods.
- D. I should decrease my intake of potassium-rich foods.
Correct Answer: B
Rationale: The correct answer is B. Decreasing the intake of purine-rich foods is essential in managing gout as purines break down into uric acid, contributing to gout symptoms. Increasing purine-rich foods would exacerbate the condition by increasing uric acid levels. Therefore, choice A is incorrect. Choices C and D are also incorrect as increasing sodium-rich foods (choice C) is not recommended for gout management, and decreasing potassium-rich foods (choice D) is unrelated to gout.
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What is an example of a subjective data?
- A. Heart rate of 68 beats per minute
- B. Yellowish sputum
- C. Client verbalized, 'I feel pain when urinating.'
- D. Noisy breathing
Correct Answer: C
Rationale: Subjective data consists of information reported by the patient, reflecting their personal experiences, sensations, or perceptions, which cannot be directly measured by the nurse. The statement 'I feel pain when urinating' is a classic example, as it conveys the patient's subjective sensation of pain, reliant on their verbal report rather than objective observation. This type of data is crucial for understanding symptoms like pain or discomfort that lack visible signs. In contrast, a heart rate of 68 beats per minute is objective, measurable via pulse check. Yellowish sputum and noisy breathing are also objective, observable through sight and sound during assessment. Subjective data, like the patient's pain report, enhances the nurse's ability to assess holistic needs, guiding further inquiry or intervention, such as checking for urinary tract issues, making it distinct from observable, objective findings.
A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse. Which of the following statements should the nurse include in the teaching?
- A. You can still eat sugar, but you must count it in your carbohydrate count for the day.
- B. You need to avoid all forms of sugar to keep your blood glucose levels under control.
- C. You can eat unlimited amounts of proteins and fats since they do not affect blood glucose levels.
- D. You will need to take an oral hypoglycemic agent every day to manage your blood glucose levels.
Correct Answer: A
Rationale: The correct statement to include in teaching a client with type 1 diabetes mellitus is that they can still eat sugar, but they must count it in their carbohydrate intake for the day. This is important because clients with type 1 diabetes need to manage their blood glucose levels by calculating their carbohydrate intake, including sugars. Choice B is incorrect because total avoidance of sugar is not necessary, but monitoring and including it in the carbohydrate count is essential. Choice C is incorrect as proteins and fats can also affect blood glucose levels and should be consumed in moderation. Choice D is incorrect since oral hypoglycemic agents are not used in type 1 diabetes mellitus, as insulin replacement therapy is the mainstay of treatment.
A client with celiac disease is being taught about dietary management. Which statement by the client indicates an understanding of the teaching?
- A. I should avoid foods that contain gluten.
- B. I should increase my intake of foods high in gluten.
- C. I should avoid foods that contain lactose.
- D. I should increase my intake of foods high in lactose.
Correct Answer: A
Rationale: The correct answer is A: 'I should avoid foods that contain gluten.' Celiac disease requires the avoidance of gluten-containing foods to manage symptoms and prevent complications. Gluten is found in wheat, barley, and rye. Choices B, C, and D are incorrect as they do not align with the dietary requirements for managing celiac disease. Increasing intake of foods high in gluten or lactose would be detrimental for someone with celiac disease.
The nurse is caring for clients in a rural health clinic and wants to promote illness prevention. Which action should the nurse take?
- A. Provide education about accident prevention
- B. Screen all clients for hypertension
- C. Refer clients with chronic conditions to a specialist
- D. Teach clients with diabetes about a diabetic diet
Correct Answer: A
Rationale: In a rural clinic, illness prevention primary prevention aims to stop disease before it starts, critical where access lags. Providing accident prevention education, like safe tractor use or fall risks, targets common rural hazards, reducing injuries proactively. Screening for hypertension is secondary, detecting issues, not preventing them. Referring chronic cases to specialists or teaching diabetic diets is tertiary, managing existing conditions, not averting onset. Accident prevention fits rural needs data shows higher injury rates in such areas empowering clients with knowledge to avoid harm. The nurse's action aligns with nursing's preventive role, addressing environmental and lifestyle risks unique to the setting, enhancing community health by tackling root causes before they escalate, a practical step given limited rural resources.
The physician has ordered Stadol (butorphanol) for a post-operative client. The nurse knows that the medication is having its intended effect if the client:
- A. Is asleep 30 minutes after the injection
- B. Asks for extra servings on his meal tray
- C. Has an increased urinary output
- D. States that he is feeling less nauseated
Correct Answer: A
Rationale: Being asleep 30 minutes post-Stadol indicates effective pain relief and sedation, its intended effect post-op extra food, urine output, or less nausea aren't primary goals. Nurses monitor response, ensuring rest and pain control, critical for recovery in surgical care.