Nokea
A client with iron-deficiency anemia 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 foods high in iron.
- B. I should decrease my intake of foods high in iron.
- C. I should increase my intake of foods high in calcium.
- D. I should decrease my intake of foods high in calcium.
Correct Answer: A
Rationale: The correct answer is A: 'I should increase my intake of foods high in iron.' Iron-deficiency anemia is managed by increasing the consumption of iron-rich foods to improve iron levels in the body. Foods high in iron include red meat, poultry, fish, beans, lentils, and iron-fortified cereals. Choices B, C, and D are incorrect because decreasing intake of iron-rich foods or increasing intake of calcium-rich foods would not address the deficiency in iron levels that characterizes iron-deficiency anemia.
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Caring is healing, it is communicated through the consciousness of the nurse to the individual being cared for. It allows access to higher human spirit.
- A. Benner
- B. Watson
- C. Leininger
- D. Swanson
Correct Answer: B
Rationale: Jean Watson's Human Caring Theory, developed in the 1970s, defines caring as a healing force transmitted through the nurse's consciousness, connecting to the patient's spirit. She sees nursing as transcending physical acts, fostering openness to a higher human essence. Unlike Benner's skill progression, Leininger's cultural focus, or Swanson's process model, Watson's approach is deeply philosophical, emphasizing transpersonal caring moments like a nurse's empathy soothing a dying patient's fear. Her 10 Carative Factors (e.g., instilling hope) guide this spiritual exchange, influencing holistic nursing practices globally, particularly in palliative care, where emotional and existential support is paramount.
The physician has prescribed Cognex (tacrine) for a client with dementia. The nurse should monitor the client for adverse reactions, which include:
- A. Increased appetite
- B. Elevated liver enzymes
- C. Hypotension
- D. Improved short-term memory
Correct Answer: B
Rationale: Elevated liver enzymes are a key adverse reaction to Cognex, requiring monitoring in dementia appetite, BP, and memory aren't primary concerns. Nurses check LFTs, ensuring safety, critical for managing Alzheimer's medication risks.
A client has a tracheostomy and requires suctioning. Which of the following actions should be taken?
- A. Hyperoxygenate the client before suctioning
- B. Insert the catheter while exhalation
- C. Apply suction after inserting the catheter
- D. Limit suctioning to no more than 15 seconds
Correct Answer: A
Rationale: Hyperoxygenating the client before suctioning is crucial to prevent hypoxia during the procedure. By using a manual resuscitation bag with 100% oxygen, the nurse should provide several breaths to the client to ensure sufficient oxygenation before starting suctioning. This approach helps maintain oxygen levels and decreases the risk of hypoxia, which may arise when suctioning interrupts the normal respiratory process. Choices B, C, and D are incorrect because inserting the catheter during exhalation, applying suction while inserting the catheter, and limiting suctioning to 15 seconds do not address the priority of hyperoxygenating the client to prevent hypoxia.
When caring for a client with a spinal cord injury, the nurse continually monitors this client for which medical emergency?
- A. Hemorrhage
- B. Hypovolemic shock
- C. Gastrointestinal atony
- D. Autonomic hyperreflexia
Correct Answer: D
Rationale: Autonomic hyperreflexia (D) is a medical emergency in spinal cord injury (SCI) above T6, causing severe hypertension from unopposed sympathetic response. Hemorrhage (A) or shock (B) requires trauma context. GI atony (C) is chronic, not emergent. D is correct. Rationale: Hyperreflexia, triggered by stimuli like bladder distension, can lead to stroke or death if untreated, requiring urgent monitoring and intervention, per SCI emergency protocols, unlike less acute complications.
Mr. Gary signed the consent form for his surgery after the nurse explained the procedure to him. This is an example of?
- A. Autonomy
- B. Informed consent
- C. Veracity
- D. Fidelity
Correct Answer: B
Rationale: Mr. Gary signing after explanation is informed consent (B) understanding precedes agreement, per ethics/law. Autonomy (A) enables choice, veracity (C) truth, fidelity (D) promises not consent-specific. B reflects the process, making it correct.