Nokea
A nurse is caring for a client who follows Halal, Islamic dietary laws. The nurse should recognize that the client will practice which of the following dietary practices?
- A. Does not eat meat and dairy products at the same meal.
- B. Does not eat birds of prey.
- C. Refrains from eating snacks between meals.
- D. Does not eat shellfish.
Correct Answer: B
Rationale: Halal dietary laws prohibit the consumption of birds of prey, as they are considered impure.
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A nurse is caring for a client who has respiratory acidosis. Which of the following pH levels should the nurse expect?
- A. pH 7.31
- B. pH 7.39
- C. pH 7.48
- D. pH 7.50
Correct Answer: A
Rationale: The correct answer is A: pH 7.31. In respiratory acidosis, there is an excess of carbon dioxide in the blood, leading to decreased pH. Normal pH range is 7.35-7.45. pH 7.31 indicates acidosis. Choice B is within the normal range, C and D are alkalotic, and E, F, G are not provided. pH 7.31 is the most accurate representation of respiratory acidosis in this scenario.
A nurse is caring for a client who had a severe traumatic brain injury 3 weeks ago, remains unconscious, and is unlikely to recover. While bathing the client, the assistive personnel (AP) talks to him about current events. The client's partner asks the nurse why the AP talks to the client. Which of the following responses should the nurse make?
- A. I'm really not sure why the assistant is talking to him. Perhaps you should ask her.
- B. Although your partner is not responding to us, he might still be able to hear.
- C. Don't let that concern you. She talks to all her clients, no matter what.
- D. She is an excellent caregiver. She has many others to care for, but she takes the time to talk to your partner.
Correct Answer: B
Rationale: The correct answer is B: Although your partner is not responding to us, he might still be able to hear. This response is correct because research shows that comatose patients can still hear and process information. Talking to the patient can provide comfort, familiarity, and potentially stimulate brain activity.
Choices A, C, and D are incorrect because they do not address the potential benefit of talking to the unconscious patient. A deflects the question, C generalizes the behavior, and D praises the caregiver without explaining the rationale behind talking to the patient.
In summary, choice B is the best response as it acknowledges the potential for the unconscious patient to hear and emphasizes the importance of continuing communication for the patient's well-being.
A nurse is interviewing a female client who does not speak the same language as the nurse. The client's partner is translating what the nurse is saying to the client. Which of the following actions should the nurse take?
- A. Arrange to complete the data collection with only the client and a translator present.
- B. Ask the client's partner to translate questions and answers for the client.
- C. Record the partner's answers to the questions and complete the assessment.
- D. Ask the partner to allow the client to provide her own answers to the nurse's questions.
Correct Answer: A
Rationale: A professional translator ensures accuracy, maintains confidentiality, and reduces potential biases from family members.
A nurse is caring for a client who has diabetes mellitus and had a below-the-knee amputation 2 days ago. Which of the following statements by the client should the nurse identify as an indication that the client has a body image disturbance?
- A. When I look in the mirror, all I see is a person without a leg.
- B. I have not always made good choices in life. I deserve to lose my leg.
- C. If my wife had paid more attention to my blood sugar levels I would not have needed an amputation.
- D. No matter how hard I work in physical therapy, I can't seem to make any progress.
Correct Answer: A
Rationale: A body image disturbance is reflected in the client's negative perception of their physical self.
A nurse is collecting data from a client following surgery for a brain tumor near the hypothalamus. For which of the following findings should the nurse monitor the client because of the risks of surgery on this area of the brain?
- A. Inability to regulate body temperature
- B. Bradycardia
- C. Visual disturbances
- D. Inability to perceive sound
Correct Answer: A
Rationale: The correct answer is A: Inability to regulate body temperature. The hypothalamus plays a crucial role in regulating body temperature. Surgery near this area can disrupt its function, leading to potential problems in thermoregulation. The nurse should monitor the client for signs of hyperthermia or hypothermia. Bradycardia (choice B) is more related to dysfunction in the cardiovascular system, not typically affected by surgery near the hypothalamus. Visual disturbances (choice C) and inability to perceive sound (choice D) are more associated with areas of the brain responsible for processing sensory information, not specifically linked to the hypothalamus.