Nokea
A low-residue diet is ordered for an adult. The nurse knows that the client understands the diet when which menu is selected?
- A. Lettuce and tomato salad, steak sandwich, orange slices
- B. Gelatin salad, mashed potatoes, sliced chicken
- C. Corn casserole, pork chop, rice
- D. Broccoli, broiled fish, sesame seed roll
Correct Answer: B
Rationale: Gelatin, mashed potatoes, and sliced chicken are low-fiber, low-residue foods, suitable for the diet. Lettuce, corn, broccoli, and sesame seeds are high-fiber, increasing residue.
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An adult is admitted with a head injury following an accident. He has a severe headache and asks the nurse why he cannot have something for pain. The nurse understands that the client should not receive a narcotic analgesic for which reason?
- A. Narcotic analgesics cause mydriasis, which will raise intracranial pressure.
- B. Narcotic analgesics are not effective for pain caused by brain trauma.
- C. Narcotic analgesics cause vomiting, which would mask a sign of increased intracranial pressure.
- D. Narcotic analgesics may depress respirations, which would cause acidosis and further brain damage.
Correct Answer: D
Rationale: Narcotics depress respirations, risking CO2 retention, acidosis, and increased intracranial pressure in head injury clients. Mydriasis, ineffectiveness, or vomiting are less critical concerns.
During the charge nurse’s morning rounds, a client says, 'I hope you will take better care of me than the nurse I had last night.' What should be the charge nurse’s initial response?
- A. Apologize for the previous nurse’s treatment
- B. Ask the client to describe what happened last night
- C. Explain that the night nurse was probably busy
- D. Reassure the client that things will be better today
Correct Answer: B
Rationale: Asking for details (B) allows the charge nurse to understand the client’s concerns and address specific issues. Apologizing (A) assumes fault, excusing the nurse (C) dismisses the concern, and reassurance (D) lacks follow-through without investigation.
During the evaluation phase for a client, the nurse should focus on
- A. All finding of physical and psychosocial stressors of the client and in the family
- B. The client's status, progress toward goal achievement, and ongoing re-evaluation
- C. Setting short and long-term goals to insure continuity of care from hospital to home
- D. Select interventions that are measurable and achievable within selected timeframes
Correct Answer: B
Rationale: The client's status, progress toward goal achievement, and ongoing re-evaluation. Evaluation focuses on assessing progress and adjusting the care plan.
The nurse is caring for a client who has a single-chamber atrial pacemaker. Which of the following findings would the nurse expect to observe on the client’s electrocardiogram strip?
- A. Pacemaker spike on the T wave
- B. Pacemaker spike before the P wave
- C. Occasional wide and distorted QRS complex
- D. Prolonged PR interval with normal QRS complex
Correct Answer: B
Rationale: A single-chamber atrial pacemaker paces the atrium, producing a spike before the P wave (B), followed by normal conduction. Spikes on T waves (A) are abnormal, wide QRS (C) suggests ventricular issues, and prolonged PR (D) is unrelated to pacing.
A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker 'force feed' the client. What is the priority nursing action?
- A. Explain to the family that this is a normal physiological response to dying
- B. Explore the family’s thoughts and concerns about the client’s refusal of food
- C. Recommend a feeding tube
- D. Tell the family that 'force feeding' the client could cause the client to choke on the food
Correct Answer: A
Rationale: Explaining that anorexia is normal in dying (A) addresses family distress and aligns with hospice goals. Exploring concerns (B) is secondary, feeding tubes (C) are inappropriate, and choking warnings (D) may escalate distress.