Nokea
A nurse is reviewing nutritional guidelines with the parents of a 2-year-old toddler. Which of the following parent statements should indicate to the nurse an understanding of the teaching?
- A. "I should keep feeding my son whole milk until he is 3 years old."
- B. "It's okay for me to give my son a cup of apple juice with each meal."
- C. "I'll give my son about 2 tablespoons of each food at mealtimes."
- D. "My son loves popcorn, and I know it is better for him than sweets."
Correct Answer: C
Rationale: The correct answer is C. Offering a variety of foods in small portions is appropriate for a 2-year-old toddler as it helps provide balanced nutrition and allows the child to explore different tastes and textures. Choice A is incorrect because whole milk is recommended up to 2 years old, not until 3 years old. Choice B is incorrect as excessive juice intake can lead to excessive sugar consumption and is not recommended. Choice D is incorrect as popcorn may pose a choking hazard for toddlers and is not a suitable alternative to sweets.
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When assessing a male client, the nurse finds that he is fatigued and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client's laboratory values to validate the existence of which condition?
- A. Hyperphosphatemia
- B. Hypocalcemia
- C. Hypermagnesemia
- D. Hypokalemia
Correct Answer: D
Rationale: The symptoms of muscle weakness, leg cramps, and cardiac dysrhythmias are indicative of hypokalemia, a condition characterized by low potassium levels. Checking the client's laboratory values for potassium will help confirm this diagnosis. Hyperphosphatemia (Choice A) is an elevated phosphate level in the blood, which is not consistent with the symptoms described. Hypocalcemia (Choice B) is a low calcium level and typically presents with different symptoms than those mentioned in the scenario. Hypermagnesemia (Choice C) is an excess of magnesium in the blood and does not align with the symptoms of muscle weakness, leg cramps, and cardiac dysrhythmias observed in the client.
A client with a left leg cast is being taught how to use crutches. Which of the following statements should indicate to the nurse that the client understands the teaching?
- A. When descending stairs, I will first shift my weight to my right (unaffected) leg.
- B. I will use crutches to support my weight on my left leg.
- C. When ascending stairs, I will lead with my left leg.
- D. I will keep my crutches under my arms for support.
Correct Answer: A
Rationale: The correct answer is A. Shifting weight to the unaffected leg when descending stairs is crucial for maintaining balance and safety. This technique helps prevent falls and distributes weight appropriately. Choices B, C, and D are incorrect because using crutches to support the weight on the injured leg, leading with the injured leg when ascending stairs, and keeping crutches under the arms are all potentially unsafe practices that could lead to further injury or accidents.
The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about hygiene habits, the nurse learns the patient takes a bath once a week and a sponge bath every other day. To provide ultimate care for this patient, which principle should the nurse keep in mind?
- A. Patients who appear unkempt may require guidance on hygiene practices.
- B. Personal preferences can be influenced by health conditions.
- C. The patient's illness may require teaching of new hygiene practices.
- D. Cultural perspectives on cleanliness can vary based on health status.
Correct Answer: C
Rationale: In this scenario, the patient's diagnosis of diabetes may necessitate adjustments to their hygiene practices. The nurse should recognize that certain illnesses, like diabetes, can impact hygiene needs. Choice A is incorrect because appearing unkempt does not necessarily indicate a lack of importance on hygiene practices; it may be due to various factors. Choice B is incorrect as health conditions can influence personal preferences and habits. Choice D is incorrect as cultural views on cleanliness are not the primary focus when addressing hygiene practices related to a specific illness.
A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles?
- A. Fidelity
- B. Autonomy
- C. Justice
- D. Nonmaleficence
Correct Answer: D
Rationale: The correct answer is D, Nonmaleficence. Nonmaleficence refers to the principle of 'do no harm.' In this scenario, questioning a potentially harmful prescription for a client with advanced age and unstable status aligns with the principle of nonmaleficence, as the nurse is advocating for the client's safety and well-being. Choice A, Fidelity, refers to being faithful and keeping promises, which is not directly related to the situation described. Choice B, Autonomy, pertains to respecting a patient's right to make their own decisions, which is not the focus of the nurse questioning the prescription. Choice C, Justice, involves fairness and equal treatment, which is not the primary ethical principle at play in this situation.
The nurse is caring for an older adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan?
- A. Encourage the patient to perform as many self-care activities as possible.
- B. Provide assistance with a bed bath to promote patient comfort.
- C. Coordinate with physical therapy for gait training.
- D. Instruct the patient to remain on bed rest to prevent fatigue.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to perform as many self-care activities as possible. For a patient who has had a stroke, promoting independence and engaging in self-care activities help maintain mobility and foster a sense of autonomy. Choices B, C, and D are incorrect because providing assistance with a bed bath, coordinating with physical therapy for gait training, or advising bed rest without indications may not be the best interventions for promoting optimal recovery and independence in a stroke patient.