A Hispanic client brings her father to the clinic because he is becoming more forgetful. He is diagnosed with Alzheimer's disease. The woman tells the nurse that she wants to try ginkgo biloba for her father, before using prescription medications. Which of the following is an appropriate response by the nurse?
- A. It is wiser to start a prescription
- B. That herb won't do your father any good
- C. You can't expect an herb to treat Alzheimer's
- D. I will let the physician know of your wishes
Correct Answer: D
Rationale: The culturally sensitive response is to notify the physician of the family member's wishes and to determine whether it is feasible. Ginkgo biloba has been shown to be of some benefit in treating dementia. The other statements are not culturally sensitive.
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A 46 year-old has returned from a heart catheterization and wants to get up to start walking 3 hours after the procedure. The nurse should:
- A. Tell the patient to remain with the leg straight for at least another hour and check the chart for activity orders.
- B. Allow the patient to begin limited ambulation with assistance.
- C. Recommend a physical therapy consultation for ambulation.
- D. Tell the patient to remain with leg straight for another 6 hours and check the chart for activity orders.
Correct Answer: A
Rationale: The patient should keep the leg straight for at least 4 hours.
Which of the following foods might a client with a hypercholesterolemia need to decrease his or her intake of?
- A. broiled catfish
- B. hamburgers
- C. wheat bread
- D. fresh apples
Correct Answer: B
Rationale: Due to the high cholesterol content of red meats, such as hamburger, intake needs to be decreased. The other options do not have high cholesterol content, so they do not need to be decreased.
Which type of dressing is recommended to place over a site when a chest tube is removed by the physician?
- A. transparent dressing
- B. colloidal dressing
- C. petrolatum gauze
- D. nonadherent dressing
Correct Answer: C
Rationale: Petrolatum gauze is recommended to place over a site when a chest tube is removed by the physician. This is because it forms an airtight seal, which the other choices do not.
A client with which of the following conditions is at risk for developing a high ammonia level?
- A. renal failure
- B. psoriasis
- C. lupus
- D. cirrhosis
Correct Answer: D
Rationale: A client with cirrhosis is at risk for developing a high ammonia level.
A small amount of bubbling is seen in the water seal of a pleural drainage system when a client coughs. What should the nurse do?
- A. Consider it a normal finding.
- B. Check the system for leaks.
- C. Clamp the chest tube.
- D. Change the drainage system.
Correct Answer: A
Rationale: A small amount of bubbling is a normal finding in the water seal of a pleural drainage system when a client coughs. It is only a problem to find continuous, excessive bubbling in the water seal, which indicates a leak.