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A client with lactose intolerance is being taught about dietary management by a nurse. Which statement by the client shows an understanding of the teaching?
- A. I should avoid foods that contain lactose.
- B. I should increase my intake of dairy products.
- C. I should avoid foods that contain gluten.
- D. I should increase my intake of high-fiber foods.
Correct Answer: A
Rationale: The correct answer is A: 'I should avoid foods that contain lactose.' Lactose intolerance results from the inability to digest lactose, a sugar found in dairy products. Avoiding foods that contain lactose is essential in managing symptoms like bloating, diarrhea, and abdominal pain. Choice B is incorrect because increasing dairy intake would worsen symptoms. Choice C is incorrect because gluten is unrelated to lactose intolerance. Choice D is incorrect because high-fiber foods are beneficial for other conditions but do not specifically address lactose intolerance.
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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 intervention should the nurse implement to prevent contractures in a patient who is immobile?
- A. Encouraging frequent changes in position
- B. Applying heat packs to stiff joints
- C. Administering muscle relaxants
- D. Using soft restraints to immobilize the extremities
Correct Answer: A
Rationale: Frequent position changes prevent contractures in immobile patients by keeping joints mobile and reducing muscle shortening risks. Heat or relaxants offer relief but don't address root immobility, and restraints worsen stiffness. Nurses use this to maintain range of motion, ensuring flexibility and function, a proactive measure against permanent musculoskeletal damage in prolonged stillness.
The nurse is assessing a post operative client who underwent a colostomy, which of the following findings will warrant further nursing interventions?
- A. The stoma appears pale and dry
- B. The stoma appears red
- C. The stoma drains a bloody drainage then progressed to greenish discharge
- D. The stoma drains a greenish discharge
Correct Answer: A
Rationale: A pale, dry stoma e.g., ischemia needs intervention (e.g., notify MD), unlike red (healthy), bloody-to-green (normal), or green (expected). Nurses assess e.g., color for complications, per ostomy care.
He proposed the theory of morality that is based on MUTUAL TRUST
- A. Freud
- B. Erikson
- C. Kohlberg
- D. Peters
Correct Answer: C
Rationale: Lawrence Kohlberg's moral development theory, from the 1950s, hinges on mutual trust e.g., a child learns fairness through reciprocal relationships. Freud's psychoanalysis, Erikson's psychosocial stages, and Peters' principle-based morality differ. Kohlberg's stages premoral (reward/punishment), conventional (social norms), post-conventional (personal ethics) explain moral growth, influencing nursing ethics education on trust-based patient interactions.
When admitting a client at risk for falls in a long-term care facility, what should the nurse do first?
- A. Complete a fall-risk assessment
- B. Place a fall-risk identification bracelet on the client
- C. Provide the client with nonskid footwear
- D. Set the bed to the lowest position
Correct Answer: A
Rationale: The initial step in caring for a client at risk for falls is to conduct a fall-risk assessment. This assessment helps the nurse gather crucial data to identify specific risks and individualized needs, guiding subsequent interventions and preventive measures. By completing a thorough assessment, the nurse can develop a targeted plan of care to mitigate fall risk and ensure the client's safety. Placing a fall-risk identification bracelet, providing nonskid footwear, or setting the bed to the lowest position may be important interventions, but these actions should be based on the findings of the fall-risk assessment, making choice A the priority.