Nokea
A nurse is documenting the progress of a client who has been recovering from a myocardial infarction. Which of the following would be most appropriate to include in the evaluation?
- A. Client's vital signs and lab results from admission.
- B. Client reports walking 500 meters without chest pain.
- C. Physician notes on the client’s progress.
- D. Medications prescribed during hospitalization.
Correct Answer: B
Rationale: The correct answer is B because it directly reflects the client's progress in physical activity, a key indicator of recovery post-myocardial infarction. Walking 500 meters without chest pain shows improved cardiovascular function and exercise tolerance. Vital signs and lab results from admission (A) are important for initial assessment but not for ongoing evaluation. Physician notes (C) may provide insights but do not directly measure the client's progress. Medications prescribed (D) are important but do not reflect the client's specific improvement in physical activity.
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Which of the ff points should a nurse include in the teaching plan for clients who have potential for hypovolemia?
- A. Avoid alcohol and caffeine
- B. Increase intake of milk and dairy products
- C. Increase intake of dried peas and beans
- D. Avoid table salt or food containing sodium
Correct Answer: A
Rationale: The correct answer is A: Avoid alcohol and caffeine. Alcohol and caffeine are diuretics that can increase urine output, leading to fluid loss and potential hypovolemia. This step is crucial in preventing further dehydration.
Summary of incorrect choices:
B: Increasing milk and dairy products can contribute to fluid intake but does not address the prevention of hypovolemia.
C: While dried peas and beans can provide nutrients, they do not specifically address fluid intake or prevention of hypovolemia.
D: Avoiding table salt or sodium-containing foods may help in reducing fluid retention but does not directly address fluid intake to prevent hypovolemia.
Which of the ff should the nurse include in the teaching plan of a client with acute bronchitis?
- A. Not coughing frequently
- B. Washing the hands frequently
- C. Consuming adequate calories
- D. Encouraging a semi-Fowler’s position
Correct Answer: B
Rationale: The correct answer is B: Washing the hands frequently. This is important for preventing the spread of infection, which is crucial in acute bronchitis. By washing hands frequently, the client can reduce the risk of transmitting the infection to others and prevent reinfection.
A: Not coughing frequently - While managing cough is important, it is not the most crucial aspect in the teaching plan for acute bronchitis.
C: Consuming adequate calories - While nutrition is important for overall health, it is not specifically related to the management of acute bronchitis.
D: Encouraging a semi-Fowler’s position - While this position can help with breathing, it is not the most important aspect in the teaching plan for acute bronchitis.
Nurse Nancy also gives a lecture at the community health center about the diet for patients with ulcerative colitis. Which one is appropriate?
- A. high calorie, low protein
- B. low fat, high fiber
- C. high protein, low residue
- D. low sodium, high carbohydrate
Correct Answer: C
Rationale: The correct answer is C: high protein, low residue. For patients with ulcerative colitis, a high protein diet helps in tissue healing and repair. Low residue foods are recommended to reduce bowel irritation. Choice A is incorrect because low protein can impair healing. Choice B is unsuitable as high fiber may worsen symptoms. Choice D is not ideal as high carbohydrate can be difficult to digest for colitis patients.
In assessing clients for pernicious anemia, the nurse should be alert for which of the following risk factors?
- A. Positive family history
- B. Infectious agents or toxins
- C. Acute or chronic blood loss
- D. Inadequate dietary intake
Correct Answer: A
Rationale: The correct answer is A: Positive family history. Pernicious anemia is an autoimmune condition where the body attacks its own intrinsic factor, leading to vitamin B12 deficiency. Genetic predisposition plays a significant role in the development of pernicious anemia. Family history is a key risk factor as individuals with a family history of pernicious anemia are more likely to develop the condition.
Summary of why the other choices are incorrect:
B: Infectious agents or toxins do not directly cause pernicious anemia, although they can lead to other types of anemia.
C: Acute or chronic blood loss can result in iron-deficiency anemia, not pernicious anemia.
D: Inadequate dietary intake of vitamin B12 can lead to vitamin B12 deficiency anemia, but pernicious anemia specifically involves the body's inability to absorb B12 due to intrinsic factor deficiency, not dietary intake alone.
A client seeks care for hopeless that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question.
- A. “Do you smoke cigarettes, cigars or pipe?”
- B. “Have you strained your voice recently?”
- C. “Do you eat a lot of red meat?”
- D. “Do you eat spicy foods?”
Correct Answer: B
Rationale: The correct answer is B: “Have you strained your voice recently?” This question is relevant to the client's symptom of hopeless, as vocal strain can contribute to this issue. Asking about voice strain helps to identify a potential cause and guides further assessment and intervention.
Choice A is not directly related to the client's primary concern and does not address the underlying cause of hopeless.
Choice C is unrelated to the client's symptom and does not provide information that is pertinent to addressing the issue at hand.
Choice D is also unrelated to the client's symptom of hopeless and does not address potential contributing factors.