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A nurse is planning a diet for a client who is iron deficient. Which of the following foods high in iron should the nurse include in the plan?
- A. Cashews
- B. Oranges
- C. Red meat
- D. Yogurt
Correct Answer: C
Rationale: Red meat is a rich source of heme iron, highly bioavailable and effective for addressing iron deficiency. Other options have less or no significant iron content.
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A nurse is caring for a client who has Meniere's disease. The nurse identifies which of the following manifestations is caused by an excessive accumulation of endolymph fluid?
- A. Myopia
- B. Vertigo
- C. Photophobia
- D. Presbycusis
Correct Answer: B
Rationale: Vertigo is a primary symptom of Meniere's disease, caused by excessive endolymph fluid in the inner ear affecting balance and spatial orientation. Myopia, photophobia, and presbycusis are unrelated to endolymph accumulation.
A nurse is providing dietary teaching to a client who has a new onset of vitamin B12 deficiency. Which of the following foods should the nurse encourage the client to include in their diet?(Select All that Apply)
- A. Steak
- B. Low fat milk
- C. Grilled salmon
- D. Green leafy vegetables
- E. Scrambled eggs
Correct Answer: A,B,C,E
Rationale: Steak, milk, salmon, and eggs are high in vitamin B12, suitable for addressing deficiency. Green leafy vegetables are not significant sources of B12, which is primarily found in animal products.
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate?
- A. Massage over erythematous bony prominences.
- B. Implement a turning schedule every 4 hr.
- C. Keep the client's skin dry with powder.
- D. Minimize skin exposure to moisture.
- E. Use pillows to keep heels off the bed surface
Correct Answer: B,E
Rationale: Using pillows to elevate heels and minimizing moisture exposure prevent pressure ulcers and skin breakdown. Massaging erythematous areas, 4-hour turning, and powder use increase skin breakdown risk.
A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?
- A. Sleep on the abdomen to facilitate wound healing.
- B. Bend at the waist to pick objects up from the floor.
- C. Notify the surgeon if white drainage develops on the eyelids.
- D. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
Correct Answer: D
Rationale: Lifting heavy objects can increase intraocular pressure, disrupting healing post-cataract surgery. Avoiding heavy lifting is critical. Other options risk complications or are unnecessary.
A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?
- A. 1 cup canned black beans
- B. 8 a whole milk
- C. 1.5 oz raisins
- D. 8 or black tea
Correct Answer: A
Rationale: Black beans are high in iron, making them an excellent dietary choice for iron deficiency anemia. Milk can inhibit iron absorption due to calcium, raisins have less iron than beans, and tea contains tannins that reduce iron absorption.