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A nurse is planning to teach a group of older adults about the prevention of osteoporosis. What information should the nurse include in the teaching?
- A. Increase intake of vitamin C
- B. Avoid weight-bearing exercises
- C. Perform weight-bearing exercises
- D. Limit sun exposure
Correct Answer: C
Rationale: The correct answer is C: Perform weight-bearing exercises. Weight-bearing exercises help maintain bone density and reduce the risk of osteoporosis in older adults. Choice A, increasing intake of vitamin C, is not directly related to osteoporosis prevention. Choice B, avoiding weight-bearing exercises, is incorrect as weight-bearing exercises are beneficial for bone health. Choice D, limiting sun exposure, is not a key factor in osteoporosis prevention as moderate sun exposure is important for vitamin D synthesis which is essential for bone health.
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A nurse is teaching about food choices for a client on a low-sodium diet. What food should the nurse recommend?
- A. Canned soup
- B. Fresh fruit
- C. Processed meats
- D. Frozen meals
Correct Answer: B
Rationale: Fresh fruit is a good option for clients on a low-sodium diet as it is naturally low in sodium. Canned soup, processed meats, and frozen meals tend to be high in sodium due to added salt and preservatives, making them unsuitable choices for individuals on a low-sodium diet.
A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and swollen. What is the nurse's priority action?
- A. Apply a cold compress
- B. Discontinue the IV line
- C. Elevate the limb
- D. Increase the IV flow rate
Correct Answer: B
Rationale: The correct answer is to discontinue the IV line. The client's symptoms of a burning sensation, redness, and swelling at the IV site indicate phlebitis, which is inflammation of the vein. The priority action in this situation is to remove the source of irritation, which is the IV line, to prevent further complications such as infection or thrombosis. Applying a cold compress may provide temporary relief but does not address the underlying issue. Elevating the limb is not the priority in this case. Increasing the IV flow rate can worsen the phlebitis by causing further irritation to the vein.
A nurse is updating the plan of care for a client with limited mobility. What intervention should the nurse include to prevent skin breakdown?
- A. Reposition the client every 4 hours
- B. Apply lotion to the skin every 2 hours
- C. Use a special mattress to reduce pressure on the skin
- D. Increase fluid intake to promote skin hydration
Correct Answer: C
Rationale: The correct answer is C: 'Use a special mattress to reduce pressure on the skin.' This intervention is crucial in preventing skin breakdown in clients with limited mobility as it helps to reduce pressure on bony prominences. Repositioning every 4 hours (Choice A) is important but may not be sufficient to prevent skin breakdown entirely. Applying lotion every 2 hours (Choice B) may not address the root cause of skin breakdown related to pressure. Increasing fluid intake (Choice D) is beneficial for overall skin health but may not directly prevent skin breakdown caused by pressure points.
A nurse in a provider's office is assessing the motor skill development of a 15-month-old toddler during a well-child visit. What gross motor skill should the nurse expect?
- A. Jumps with both feet
- B. Runs with coordination
- C. Walks without assistance
- D. Kicks a ball forward
Correct Answer: C
Rationale: At 15 months, a toddler should be able to walk without assistance. Walking without assistance is a major gross motor skill milestone at this age, indicating the child's physical development and coordination. Choices A, B, and D are developmentally inappropriate for a 15-month-old. Jumping with both feet, running with coordination, and kicking a ball forward typically develop later in a child's growth and are more advanced skills compared to walking independently.
A healthcare provider is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the healthcare provider use?
- A. Verbal self-report
- B. Pain scale
- C. Behavioral indicators
- D. Observing facial expressions
Correct Answer: C
Rationale: In clients with dementia and difficulty communicating, using behavioral indicators such as agitation and restlessness is more reliable for assessing pain than relying on verbal self-report, pain scales, or observing facial expressions. Verbal self-report may not be possible due to communication challenges, pain scales may be difficult for the client to comprehend, and observing facial expressions alone may not provide a comprehensive assessment of pain in individuals with dementia.