Nokea
A client with urinary tract calculi needs to avoid which of the following foods?
- A. lettuce
- B. cheese
- C. apples
- D. broccoli
Correct Answer: B
Rationale: A client with urinary tract calculi needs to avoid foods high in calcium to prevent the formation of more stones. Cheese is high in calcium, so it should be avoided. Lettuce, apples, and broccoli are not typically associated with high calcium content and are safe options for individuals with urinary tract calculi. Therefore, the correct answer is cheese. Choices A, C, and D are not high in calcium and are safe for consumption by individuals with urinary tract calculi.
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What is the primary sign of displacement following a total hip replacement?
- A. pain on movement and weight bearing
- B. hemorrhage
- C. affected leg appearing 1-2 inches longer
- D. edema in the area of the incision
Correct Answer: A
Rationale: The correct answer is pain on movement and weight bearing. This pain is the primary sign of prosthesis displacement after a total hip replacement, indicating pressure on nerves or muscles due to dislocation. Hemorrhage is not typically associated with prosthesis displacement. While the affected leg may appear longer, this is not the primary sign of displacement; it might actually be shorter due to muscle spasm. Edema in the incision area is not a primary indicator of prosthesis displacement.
The death of a beloved spouse places the surviving partner in which type of crisis?
- A. maturational
- B. reactive
- C. nonreactive
- D. situational
Correct Answer: D
Rationale: The correct answer is 'situational.' A situational crisis is an unexpected, unplanned event, such as the death of a spouse, which can lead to significant distress. Option A is incorrect because a maturational crisis is related to normal life transitions like getting married or retiring. Choices B and C are incorrect as they do not represent recognized crisis states in the context of the scenario provided.
When assessing a client in the Emergency Department whose membranes have ruptured, the nurse notes that the fluid is a greenish color. What is the cause of this greenish coloration?
- A. blood
- B. meconium
- C. hydramnios
- D. caput
Correct Answer: B
Rationale: The correct answer is B: meconium. Greenish amniotic fluid passed when the fetus is in a cephalic (head) presentation might indicate fetal distress. A fetus in the breech presentation passes meconium due to compression on the intestinal tract. Choice A, blood, is incorrect as blood in the amniotic fluid would present as a different color. Choice C, hydramnios, refers to an excess of amniotic fluid and would not cause the greenish coloration. Choice D, caput, is swelling of a newborn's scalp and is not related to the color of the amniotic fluid.
Which of the following nursing diagnoses is most appropriate for the client experiencing acute pancreatitis?
- A. Confusion
- B. Latex Allergy
- C. Acute Pain
- D. Constipation
Correct Answer: C
Rationale: Acute Pain is the most appropriate nursing diagnosis for a client experiencing acute pancreatitis because it is a common symptom associated with this condition. Pancreatitis often presents with severe abdominal pain that may radiate to the back. Confusion, Latex Allergy, and Constipation are not typically associated with acute pancreatitis. Confusion may occur in severe cases of pancreatitis with complications, but acute pain is the priority nursing diagnosis due to its prevalence and impact on the client's well-being.
The client seeks advice from the nurse regarding issues with flatus due to colostomy. Which food should the nurse recommend?
- A. High-fiber foods, such as bran.
- B. Cruciferous vegetables, such as cabbage, broccoli, and kale.
- C. Carbonated beverages.
- D. Yogurt.
Correct Answer: D
Rationale: The correct answer is yogurt. Yogurt can help reduce gas formation in clients with a colostomy. High-fiber foods like bran can stimulate peristalsis and increase flatulence, which is not helpful in this situation. Cruciferous vegetables, such as cabbage, broccoli, and kale, and beans tend to increase gas formation. Carbonated beverages, along with smoking, chewing gum, and drinking fluids with a straw, can also increase gas formation. Therefore, the nurse should recommend yogurt to help alleviate the client's issues with flatus.