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A nurse is caring for a client who requires a clear liquid diet. Which of the following foods should the nurse allow the client to have?
- A. Grape juice
- B. Lemon sherbet
- C. Skim milk
- D. Carrot juice
Correct Answer: A
Rationale: The correct answer is A: Grape juice. A clear liquid diet includes transparent liquids like water, broth, tea, and clear juices without pulp. Grape juice fits this criteria as it is a clear liquid that is easily digestible. Lemon sherbet (B) contains dairy and solid components, not suitable for a clear liquid diet. Skim milk (C) is a dairy product and not transparent. Carrot juice (D) has pulp and is not considered a clear liquid.
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A nurse is talking with a client who is beginning a program of moderate exercise. When the nurse reminds the client of the importance of doing warm-up exercises, the client asks why. Which of the following reasons should the nurse give?
- A. Stabilizes body temperature
- B. Enhances relaxation
- C. Reduces the risk of injury
- D. Readjusts to baseline function
Correct Answer: C
Rationale: The correct answer is C: Reduces the risk of injury. Warm-up exercises help increase blood flow to muscles, making them more flexible and responsive. This reduces the risk of muscle strains and injuries during exercise. Choice A is incorrect because while warm-up exercises may help regulate body temperature during exercise, that is not the primary reason for warm-ups. Choice B is incorrect as the primary purpose of warm-up exercises is not necessarily to enhance relaxation. Choice D is incorrect as warm-up exercises do not specifically readjust to baseline function; they prepare the body for exercise.
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 reviewing the laboratory results of a client and notes a calcium level of 7.2 mg/dL. Which of the following findings should the nurse expect?
- A. Hypoactive deep-tendon reflexes
- B. Numbness of extremities
- C. Dry, sticky mucous membranes
- D. Decreased bowel sounds
Correct Answer: B
Rationale: The correct answer is B: Numbness of extremities. A calcium level of 7.2 mg/dL indicates hypocalcemia, which can lead to neuromuscular excitability and tingling sensations. Numbness of extremities is a common symptom of hypocalcemia due to its effect on nerve function. Hypoactive deep-tendon reflexes (choice A) are associated with hypercalcemia, not hypocalcemia. Dry, sticky mucous membranes (choice C) are more indicative of dehydration. Decreased bowel sounds (choice D) may be seen in conditions affecting the gastrointestinal tract, but are not directly related to calcium levels.
A nurse is caring for four clients. Which of the following clients should the nurse expect to experience anticipatory grief?
- A. A client who has recently given up a child for adoption
- B. A client who experiences traumatic amputation of an extremity
- C. A client whose son committed suicide
- D. A client who has a new diagnosis of metastatic liver cancer
Correct Answer: D
Rationale: Anticipatory grief occurs when an individual knows a loss is imminent, as in terminal cancer.
A nurse is caring for a client who has hemophilia and has developed hemarthrosis of the left knee. Which of the following actions should the nurse take?
- A. Administer low-dose aspirin.
- B. Apply heat to the knee.
- C. Administer analgesics IM.
- D. Elevate the knee.
Correct Answer: D
Rationale: The correct answer is D: Elevate the knee. Elevating the knee helps reduce swelling and promote venous return, which can help alleviate pain and prevent further bleeding in hemarthrosis. Administering low-dose aspirin (A) is contraindicated in hemophilia as it can increase the risk of bleeding. Applying heat (B) can exacerbate bleeding by increasing blood flow to the area. Administering analgesics IM (C) may provide pain relief but does not address the underlying issue of bleeding.