Nokea
A male client has a history of diverticulosis. He has questions about the foods that he should eat. His nurse gives him the following information:
- A. He should be on a high-fiber diet.
- B. He should eat a low-residue diet.
- C. He should drink minimal amounts of fluids.
- D. He does not need to make any modifications.
Correct Answer: A
Rationale: Clients with diverticulosis should maintain a high-fiber diet and prevent constipation with bran or bulk laxatives. Low-residue diets lead to constipation and are contraindicated in clients with diverticulosis. Clients with diverticulosis should drink at least eight glasses of water each day to prevent constipation. Clients with diverticulosis should modify their diet to include high-fiber foods and bulk laxatives.
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A client has a tentative diagnosis of myasthenia gravis. The nurse recognizes that myasthenia gravis involves:
- A. Loss of the myelin sheath in portions of the brain and spinal cord
- B. An interruption in the transmission of impulses from nerve endings to muscles
- C. Progressive weakness and loss of sensation that begins in the lower extremities
- D. Loss of coordination and stiff 'cogwheel' rigidity
Correct Answer: B
Rationale: Myasthenia gravis is caused by autoantibodies blocking acetylcholine receptors, interrupting nerve impulse transmission to muscles, leading to weakness.
Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?
- A. She uses the bulb syringe to help clear her baby's nose when milk is regurgitated.
- B. She places her infant on her right side after feeding her.
- C. She props the bottle in the crib to feed her baby, which allows her to write birth announcements and feed her baby at the same time.
- D. She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.
Correct Answer: C
Rationale: This practice is the proper use of the bulb syringe to clear the infant's airway in case of regurgitation. Placing the infant on either side or on the stomach prevents aspiration of regurgitated milk. 'Bottle propping' is an unsafe practice because it increases the likelihood of aspiration. This practice is one correct way of burping an infant.
The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 12 hours if needed. The most likely rationale for this order is:
- A. The client will settle down more quickly if he thinks the staff is medicating him
- B. The medication will sedate the client until the physician arrives
- C. Haloperidol is a minor tranquilizer and will not oversedate the client
- D. Rapid neuroleptization is the most effective approach to care for the violent or potentially violent client
Correct Answer: D
Rationale: If the client could think logically, he would not be paranoid. In fact, he is probably suspicious of the staff, too. Newly admitted clients frequently experience high levels of anxiety, which can contribute to delusions. The goal of pharmacological intervention is to calm the client and assist with reality-based thinking, not to sedate him. Haloperidol is a neuroleptic and antipsychotic drug, not a minor tranquilizer. Haloperidol is a high-potency neuroleptic and first-line choice for rapid neuroleptization, with low potential for sedation.
The parents of a child with cystic fibrosis ask what determines the prognosis of the disease. The nurse knows that the greatest determinant of the prognosis is:
- A. The degree of pulmonary involvement
- B. The ability to maintain an ideal weight
Correct Answer: A
Rationale: Pulmonary involvement is the primary determinant of prognosis in cystic fibrosis, as progressive lung disease is the leading cause of morbidity and mortality.
A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate?
- A. Put in a nasogastric tube and lavage the child's stomach.
- B. Monitor muscular status.
- C. Teach mother poison prevention techniques.
- D. Place child on respiratory assistance.
Correct Answer: A
Rationale: The immediate treatment for drug overdose is removal of the drug from the stomach by either forced emesis or gastric lavage. The child's unconscious state prohibits forced emesis. Toxic amounts of salicylates directly affect the respiratory system, which could lead to respiratory failure. The mother's anxiety is probably so high that preventive guidance will be ineffective. Respiratory assistance is not needed if the child's respiratory function is unaltered.