Nokea
A nurse is caring for a client who practices Orthodox Judaism. The nurse should identify that which of the following foods together on the same dinner tray violates the client's religious practices?
- A. Kosher roast beef and ice cream
- B. Carrot sticks and cottage cheese
- C. Macaroni and cheese
- D. Kosher chicken breast and boiled potatoes
Correct Answer: A
Rationale: The correct answer is A: Kosher roast beef and ice cream. In Orthodox Judaism, meat and dairy products cannot be consumed together. Kosher laws prohibit mixing meat and dairy in the same meal or on the same plate to maintain dietary restrictions. Choices B, C, and D do not violate this rule as they do not mix meat and dairy products. Carrot sticks and cottage cheese (B), macaroni and cheese (C), and kosher chicken breast and boiled potatoes (D) are all permissible combinations in Orthodox Judaism.
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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 caring for several clients at various developmental stages. The nurse understands that according to Erikson, acceptance of death occurs at which of the following stages of psychosocial development?
- A. Autonomy vs. Shame and Doubt
- B. Generativity vs. Stagnation
- C. Identity vs. Role Diffusion
- D. Integrity vs. Despair
Correct Answer: D
Rationale: The correct answer is D: Integrity vs. Despair. According to Erikson's psychosocial development theory, acceptance of death occurs during the final stage of life, which is Integrity vs. Despair. In this stage, individuals reflect on their lives and come to terms with their mortality, finding a sense of fulfillment and wisdom. Option A (Autonomy vs. Shame and Doubt) focuses on developing a sense of independence in early childhood. Option B (Generativity vs. Stagnation) pertains to middle adulthood and concerns contributing to society and future generations. Option C (Identity vs. Role Diffusion) relates to adolescence and the formation of a sense of self. These stages do not specifically address acceptance of death.
A newly licensed nurse has obtained a capillary glucose level from a client that produced inaccurate results and reports this to the charge nurse. Which of the following actions should the charge nurse take?
- A. Assign another nurse to be responsible for obtaining capillary glucose levels.
- B. Verify that the newly licensed nurse attended the staff education class about capillary glucose levels.
- C. Repeat the capillary glucose levels.
- D. Recheck the next scheduled capillary glucose level immediately following the nurse's.
Correct Answer: C
Rationale: The correct answer is C: Repeat the capillary glucose levels. This action should be taken to confirm the accuracy of the initial results. By repeating the test, the charge nurse can determine if the inaccuracy was due to a procedural error or if there is an issue with the equipment. This step ensures that the client receives proper care based on accurate information.
Assigning another nurse (choice A) does not address the root cause of the inaccurate results. Verifying attendance at an education class (choice B) is not as immediate or relevant as repeating the test. Rechecking the next scheduled level (choice D) without verifying the accuracy of the initial result may lead to continued inaccuracies in care.
A nurse is reinforcing teaching with a client who is to collect stool at home for a fecal occult blood test (FOBT). Which of the following should the nurse instruct the client to avoid for at least 3 days before the test?
- A. Whole grain cereal
- B. Magnesium hydroxide
- C. Orange juice
- D. Acetaminophen
Correct Answer: B
Rationale: The correct answer is B: Magnesium hydroxide. This is because magnesium hydroxide, commonly found in antacids and laxatives, can cause false-positive results in a fecal occult blood test (FOBT) due to its chemical reaction with the test reagents. Instructing the client to avoid magnesium hydroxide for at least 3 days before the test ensures accurate results.
Incorrect choices:
A: Whole grain cereal - Whole grain cereal does not interfere with FOBT results.
C: Orange juice - Orange juice does not impact FOBT results.
D: Acetaminophen - Acetaminophen does not affect FOBT results.
Therefore, avoiding magnesium hydroxide is crucial to obtaining reliable results in the FOBT.
A nurse is assisting in preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following alterations is appropriate for the nurse to include?
- A. Decreased muscle mass
- B. Thickened vertebral disks
- C. Decreased chest width
- D. Increased force of isometric contractions
Correct Answer: A
Rationale: The correct answer is A: Decreased muscle mass. As individuals age, there is a natural decline in muscle mass known as sarcopenia. This is due to a decrease in muscle fiber size and number. The nurse should include this alteration in the presentation because it is a common age-related musculoskeletal change that can lead to weakness, decreased mobility, and increased risk of falls in older adults.
Choices B, C, and D are incorrect because thickened vertebral disks, decreased chest width, and increased force of isometric contractions are not typical age-related musculoskeletal changes. Thickened vertebral disks are more associated with degenerative disc disease, decreased chest width is not a common age-related change, and increased force of isometric contractions is not a typical alteration seen in older adults.