Nokea
A nurse is reinforcing teaching with a client who has Crohn's Disease and is experiencing frequent cramping and diarrhea. Which of the following statements should the nurse include in the teaching?
- A. Increase your caloric intake by eating foods high in protein.
- B. Include fresh fruits and vegetables at each meal.
- C. Maintain your weight by eating high-fat foods.
- D. Drink whole milk to ensure adequate calcium intake.
Correct Answer: A
Rationale: The correct answer is A. Increasing caloric intake by eating foods high in protein can help Crohn's Disease patients maintain their weight and manage symptoms. Choice B is incorrect because fresh fruits and vegetables may exacerbate symptoms due to their high fiber content. Choice C is incorrect as high-fat foods can be difficult to digest and may worsen symptoms. Choice D is incorrect because whole milk can be problematic for individuals with Crohn's Disease due to its high fat content.
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The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is
- A. Heart rate
- B. Pedal pulses
- C. Lung sounds
- D. Pupil responses
Correct Answer: D
Rationale: Assessing pupil responses is crucial in a client with hypertensive crisis to monitor for signs of increased intracranial pressure, which can indicate potential neurological complications. While heart rate, pedal pulses, and lung sounds are important assessments, they do not take precedence over neurological assessments in this critical situation.
While assessing several clients in a long-term health care facility, which client is at the highest risk for developing decubitus ulcers?
- A. A 79-year-old malnourished client on bed rest
- B. An obese client who uses a wheelchair
- C. A client who had 3 incontinent diarrhea stools
- D. An 80-year-old ambulatory diabetic client
Correct Answer: A
Rationale: The correct answer is A: A 79-year-old malnourished client on bed rest. This client is at the highest risk for developing decubitus ulcers due to poor nutrition and immobility. Malnutrition can impair tissue healing and increase susceptibility to skin breakdown, while prolonged bed rest can lead to pressure ulcers. Choice B is incorrect because obesity can cushion pressure points and reduce the risk of pressure ulcers. Choice C is incorrect as incontinence predisposes to moisture-associated skin damage rather than pressure ulcers. Choice D is incorrect as an ambulatory client is less likely to develop pressure ulcers compared to bedridden clients.
A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?
- A. Cut the child's hair short to remove the nits
- B. Apply warm soaks to the head twice daily
- C. Wash the child's linen and clothing in a bleach solution
- D. Application of pediculicides
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 60-year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void?
- A. Have him drink several glasses of water
- B. Crede the bladder from the bottom to the top
- C. Assist him to stand by the side of the bed to void
- D. Wait 2 hours and have him try to void again
Correct Answer: C
Rationale: Assisting the client to stand by the side of the bed to void is the most appropriate action. This position can help stimulate voiding due to gravity and normal positioning. Having the client drink water (Choice A) may help, but assisting him to stand is more effective. Crede maneuver (Choice B) is not recommended as it can increase the risk of bladder trauma. Waiting for 2 hours (Choice D) without taking any action is not proactive in addressing the client's inability to void.
A nurse is reviewing a client's admission laboratory findings that indicate the client has hyponatremia. Which of the following laboratory findings should the nurse expect to be below the expected reference range?
- A. Magnesium
- B. Calcium
- C. Chloride
- D. Potassium
Correct Answer: C
Rationale: The correct answer is C: Chloride. Chloride levels are typically low in cases of hyponatremia, as it often accompanies sodium loss. Magnesium (choice A) is not directly related to hyponatremia. Calcium (choice B) and Potassium (choice D) levels are usually not significantly affected by hyponatremia, making them less likely to be below the expected reference range in this scenario.