A nurse is caring for a client receiving oxygen therapy via a mask. What is an important nursing intervention to prevent pressure ulcers on the client's face?
- A. Frequently adjusting the mask to relieve pressure
- B. Applying petroleum jelly to the areas of skin contact
- C. Placing padding between the mask and the client's skin
- D. Assessing the client's facial skin integrity regularly
Correct Answer: C
Rationale: Placing padding between the mask and skin (C) prevents pressure ulcers by cushioning contact points, reducing friction and pressure. Frequent adjustments (A) disrupt fit. Petroleum jelly (B) compromises seal. Regular assessment (D) detects, not prevents. Padding is proactive, per skin care standards, ensuring mask safety.
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A client has a new diagnosis of hyperthyroidism and is being taught about dietary management. Which of the following statements should the nurse include in the teaching?
- A. You should increase your intake of iodine-rich foods.
- B. You should avoid foods that contain iodine.
- C. You should increase your intake of dairy products.
- D. You should avoid foods that contain gluten.
Correct Answer: B
Rationale: The correct answer is B. In hyperthyroidism, it is advisable to avoid foods that contain iodine to help manage the condition and prevent complications. Excessive iodine intake can exacerbate hyperthyroidism symptoms by stimulating the thyroid gland. Therefore, the nurse should include information about avoiding iodine-rich foods in the client's dietary management teaching. Choices A, C, and D are incorrect because increasing intake of iodine-rich foods can worsen hyperthyroidism symptoms, increasing dairy products is not specific to managing hyperthyroidism, and avoiding gluten is more relevant for conditions like celiac disease, not hyperthyroidism.
The client is in stress because he was told by the physician he needs to undergo surgery for removal of tumor in his bladder. Which of the following are effects of sympatho-adrenomedullary response by the client? 1. Constipation 2. Urinary frequency 3. Hyperglycemia 4. Increased blood pressure
- A. 3,4
- B. 1,3,4
- C. 1,2,4
- D. 1,4
Correct Answer: A
Rationale: The sympatho-adrenomedullary response, part of the fight-or-flight reaction to stress (surgery news), releases catecholamines like epinephrine, causing hyperglycemia (3) and increased blood pressure (4). Hyperglycemia results from glycogenolysis to fuel energy needs. Blood pressure rises due to vasoconstriction and increased heart rate. Constipation (1) isn't immediate; stress slows digestion long-term. Urinary frequency (2) contradicts the response's fluid retention. Only 3 and 4 (A) match acute sympathetic activation, making it correct over broader or incorrect combinations.
Mr. Gary monitors his blood sugar daily for diabetes. This is an example of?
- A. Chronic disease management
- B. Acute care
- C. Health promotion
- D. Quality improvement
Correct Answer: A
Rationale: Daily blood sugar monitoring for diabetes is chronic disease management (A) ongoing control, per definition. Acute (B) is short, promotion (C) prevents, QI (D) enhances not chronic-specific. A fits long-term care, making it correct.
An action that the nurse should take to use a wide base of support when assisting a client to get up in a chair is:
- A. Bend at the waist and place arms under client's arms and lift.
- B. Face of client, band knees and place hands on client's forearms and lift.
- C. Spread his/her feet apart.
- D. Tighten his/her pelvic muscles.
Correct Answer: C
Rationale: Spreading feet apart creates a wide base of support, stabilizing the nurse's center of gravity when lifting a client from bed to chair. This enhances balance, reducing fall risk e.g., shoulder-width stance supports a 70-kg patient. Bending at the waist risks back strain, lacking leg leverage, and no base is specified. Facing the client, bending knees, and holding forearms uses proper mechanics but omits base width less explicit. Tightening pelvic muscles aids core strength, not base stability. A wide stance, per ergonomic principles, ensures safe transfer, protecting nurse and client, making it the essential action in this context.
You partially darken a room and ask the client to look straight ahead. You use a penlight and, approaching from the side you shine the light, it constricts. You remove the light and then shine it on the same pupil again. You also observe the response of the other pupil. You would normally find the other pupil doing which of the following things?
- A. not make any change in size
- B. dilate in an oppositional response to the light
- C. first constrict, then dilate larger than the other pupil
- D. constrict in consensual response
Correct Answer: D
Rationale: The other pupil constricts consensually when light hits one, a normal reflex. No change, dilation, or mixed response indicates abnormality. Nurses test this for brain function.