Nokea
Which of the following is a normal change observed in an elderly individual?
- A. Enhanced sense of taste
- B. Increased appetite
- C. Frequent urination
- D. Lens thinning
Correct Answer: C
Rationale: The correct answer is C, frequent urination. As people age, they may experience physiological changes that can lead to an increased frequency of urination. This is due to a decrease in bladder capacity and increased bladder irritability, which are normal age-related changes. On the contrary, the sense of taste (Choice A) and appetite (Choice B) often decrease with age, not increase. As for Choice D, the lens of the eye actually thickens with age, not thins, leading to conditions like presbyopia. Therefore, Choices A, B, and D are incorrect.
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Which type of bath would you recommend for a patient experiencing pruritus?
- A. Saline
- B. Colloidal (oatmeal)
- C. Water
- D. Sodium bicarbonate
Correct Answer: B
Rationale: The best choice for a pruritus (itching) patient is a colloidal (oatmeal) bath, as it is known for its soothing effect on itchy, irritated skin. Saline, water, and sodium bicarbonate baths may not provide the same level of relief for pruritus. The nursing care should involve comprehensive assessments and appropriate interventions to optimize patient outcomes. In this case, a colloidal bath is the most suitable intervention for a patient experiencing pruritus.
24 hours after the creation of a colostomy, what should Nurse Violy identify as the normal appearance of the stoma?
- A. Pink, moist, and slightly protruding from the abdomen
- B. Gray, moist, and slightly protruding from the abdomen
- C. Pink, dry, and slightly protruding from the abdomen
- D. Red, moist, and slightly protruding from the abdomen
Correct Answer: A
Rationale: Following colostomy surgery, a healthy stoma should appear pink, moist, and slightly protruding from the abdomen, which is why option 'A' is the correct answer. A gray stoma (choice 'B') could indicate poor blood supply or necrosis, which is a serious complication. A dry stoma (choice 'C') is also not normal as it should be moist; a dry stoma may suggest dehydration or other complications. While a stoma can appear red (choice 'D'), this is not typically the normal color; it should usually be pink. Therefore, it's important for healthcare professionals to correctly identify the normal and abnormal appearances of a stoma to ensure proper patient care.
What instruction should a nurse include when teaching a client who has recently been prescribed a low-sodium diet?
- A. Avoid foods such as smoked meats and frozen dinners.
- B. Select foods with less than 4g of sodium as indicated on food labels.
- C. Use soy sauce for flavoring foods instead of table salt.
- D. Processed and prepared foods are typically low in sodium.
Correct Answer: A
Rationale: The correct answer is A, which directs the client to avoid foods such as smoked meats and frozen dinners. These types of foods are typically high in sodium, making them unsuitable for a low-sodium diet. Option B is incorrect because foods with less than 4g of sodium might still be high in sodium for individuals on low-sodium diets. The daily recommended intake of sodium for a low-sodium diet is usually around 1.5g to 2g. Hence, 4g of sodium in a single food product can be excessive. Option C is incorrect as soy sauce, although a different source of flavor, is also high in sodium and should be used sparingly, if at all, in a low-sodium diet. Option D is incorrect because processed and prepared foods are usually not low in sodium. In fact, these foods often have high sodium content due to added salts and preservatives.
Which of the following actions would be of highest priority with regards to the external shunt?
- A. Avoid taking blood pressure or blood sample from the arm with the shunt
- B. Instruct the patient not to exercise the arm with the shunt
- C. Heparinize the shunt daily
- D. Change the dressing of the shunt daily
Correct Answer: C
Rationale: Heparinizing the shunt daily (choice C) is the highest priority action as it prevents the formation of blood clots that can occlude the shunt, leading to potential complications such as thrombosis. Avoiding taking blood pressure or blood samples from the arm with the shunt (choice A) is also important, but secondary to heparinizing the shunt. Similarly, instructing the patient not to exercise the arm with the shunt (choice B) can help prevent unnecessary strain on the shunt, but it is not as critical as preventing clot formation. Changing the dressing of the shunt daily (choice D) is a standard nursing care practice to prevent infection, but again, it is not as critical as ensuring the shunt remains patent through daily heparinization.
Which of the following is a tricyclic antidepressant drug?
- A. Venlafaxine (Effexor)
- B. Fluoxetine (Prozac)
- C. Sertraline (Zoloft)
- D. Imipramine (Tofranil)
Correct Answer: D
Rationale: Imipramine (Tofranil) is a tricyclic antidepressant drug. This class of medications is used to treat depression, and they work by increasing the levels of certain chemicals in the brain that help lift mood. On the other hand, Venlafaxine (Effexor) is a serotonin and norepinephrine reuptake inhibitor (SNRI), Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI), and Sertraline (Zoloft) is also an SSRI. Therefore, they are not classified as tricyclic antidepressants.