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A nurse is assisting an adolescent client in the selection of complementary protein sources on the lunch menu. The client is a vegetarian who eats milk products but does not like beans. Which of the following food items should the nurse recommend?
- A. Peanut butter and jelly with enriched bread
- B. Baked potato with sour cream
- C. Bagel with cream cheese
- D. Fruit salad and carrot sticks
Correct Answer: A
Rationale: Peanut butter and enriched bread provide complementary proteins, which are important for a vegetarian diet. Peanut butter is a good source of protein and when paired with enriched bread, it forms a complete protein source. Choice B, baked potato with sour cream, lacks complete protein. Choice C, bagel with cream cheese, also does not provide a complete protein source. Choice D, fruit salad and carrot sticks, do not contain sufficient protein to serve as a main protein source for a vegetarian diet.
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Why is it important for the healthcare provider to monitor blood pressure in clients receiving antipsychotic drugs?
- A. Orthostatic hypotension is a common side effect.
- B. Most antipsychotic drugs cause elevated blood pressure.
- C. This provides information on the amount of sodium allowed in the diet.
- D. It will indicate the need to institute anti-parkinsonian drugs.
Correct Answer: A
Rationale: The correct answer is A because monitoring for orthostatic hypotension is crucial when clients are receiving antipsychotic drugs since it is a common side effect. Orthostatic hypotension can lead to symptoms like dizziness and falls, making it essential to monitor blood pressure regularly. Choices B, C, and D are incorrect because most antipsychotic drugs do not typically cause elevated blood pressure, monitoring blood pressure is not directly related to the amount of sodium in the diet, and blood pressure monitoring is not primarily used to determine the need for anti-parkinsonian drugs in clients receiving antipsychotic medications.
A client with a history of asthma is admitted to the emergency department with difficulty breathing. Which of these assessments is the highest priority for the nurse to perform?
- A. Auscultation of breath sounds
- B. Measurement of peak expiratory flow
- C. Observation of the client's use of accessory muscles
- D. Assessment of the client's skin color
Correct Answer: A
Rationale: Auscultation of breath sounds is the highest priority assessment in a client with a history of asthma experiencing difficulty breathing. It helps the nurse evaluate the severity of the asthma exacerbation by listening for wheezing, crackles, or decreased breath sounds. This assessment guides treatment decisions, such as administering bronchodilators or oxygen therapy. Measurement of peak expiratory flow, although important in assessing asthma severity, may not be feasible in an emergency situation where immediate intervention is needed. Observation of accessory muscle use and assessment of skin color are also important assessments in asthma exacerbation, but auscultation of breath sounds takes precedence in determining the need for urgent interventions.
A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?
- A. Cut the child's hair short to remove the nits
- B. Apply warm soaks to the head twice daily
- C. Wash the child's linen and clothing in a bleach solution
- D. Application of pediculicides
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
- A. Exercise by doing weight-bearing activities
- B. Exercise to reduce weight
- C. Avoid exercise activities that increase the risk of fracture
- D. Exercise to strengthen muscles and thereby protect bones
Correct Answer: A
Rationale: The correct answer is A: Exercise by doing weight-bearing activities. Weight-bearing activities help strengthen bones and prevent further bone loss in clients with osteoporosis. This type of exercise includes activities like walking, dancing, and weightlifting, which help improve bone density. Choice B is incorrect because the primary focus should be on bone health, not weight reduction. Choice C is incorrect as avoiding all exercise activities that increase the risk of fracture can lead to muscle weakness and a decline in bone health. Choice D is also incorrect because while strengthening muscles is beneficial, the emphasis for osteoporosis management should be on weight-bearing exercises specifically.
A client who has chronic lymphocytic leukemia is starting chemotherapy treatments and asks if she needs to make any dietary changes. Which of the following statements by the nurse is appropriate?
- A. Use sugar-free gum if you experience a metallic taste in your mouth.
- B. Drink fluids at mealtime to prevent early satiety.
- C. Foods that are higher in fat can help nausea.
- D. Raw fruits and vegetables will be easier for your body to digest.
Correct Answer: A
Rationale: The correct answer is A. Using sugar-free gum can help alleviate the metallic taste often experienced during chemotherapy treatments. Choices B, C, and D are incorrect. Drinking fluids at mealtime may worsen early satiety, foods higher in fat can exacerbate nausea, and raw fruits and vegetables may be harder for the body to digest and may pose a risk of infection for individuals with compromised immune systems.