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A nurse is contributing to the plan of care for a client who has had severe diarrhea for the past 3 days and is now beginning solid foods. Which of the following foods should the nurse include in the plan of care?
- A. Applesauce
- B. Orange slices
- C. Bran cereal
- D. Cottage cheese
Correct Answer: A
Rationale: Applesauce is gentle on the digestive system and helps firm stools, suitable for reintroducing solids after diarrhea.
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A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care?
- A. Restrict visitors to family members until the client is able to wear a prosthesis.
- B. Encourage the client to talk with another client who completed rehabilitation for amputation.
- C. Instruct the client to ignore phantom pain sensations.
- D. Suggest that family members bring clothing for the client from home.
- E. Ask the client to describe her feelings about the loss of the affected limb.
Correct Answer: B,D,E
Rationale: Peer support, familiar clothing, and addressing feelings promote psychological adjustment and rehabilitation; restricting visitors or ignoring phantom pain is not therapeutic.
A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation?
- A. Current medication prescriptions
- B. Primary health problem
- C. Number of family members who have visited
- D. Admission vital signs from 1 week ago
- E. Scheduled times for dressing changes
Correct Answer: A,B,E
Rationale: Medications, primary problem, and dressing schedules are critical for continuity of care in the ICU; family visits and old vital signs are less relevant.
A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?
- A. Plan to hire a home care aid to perform all of your ADLs.
- B. You will not become fatigued when you use assistive devices.
- C. Install grab bars in your shower to assist with your balance.
- D. Place a towel in the shower to prevent slipping.
Correct Answer: C
Rationale: Installing grab bars enhances safety and supports independence in ADLs post-CVA, addressing balance issues.
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
- A. It is common for the skin on my breasts to dimple.
- B. I will perform breast exams every other month.
- C. It is common for one breast to be larger than the other.
- D. I will perform breast exams the day my period begins.
Correct Answer: C
Rationale: It is normal for one breast to be slightly larger than the other, and this statement reflects an understanding of breast self-examination teaching.
A nurse is collecting data from a client who underwent a thyroidectomy 4 hr ago. Which of the following client findings indicates a complication of the procedure?
- A. Soreness at the incision site
- B. Serosanguineous drainage on the dressing
- C. Report of sore throat
- D. Tingling of the fingers
Correct Answer: D
Rationale: Tingling of the fingers suggests hypocalcemia due to parathyroid gland damage during thyroidectomy, a potential complication.