Nokea
A nurse is reviewing the laboratory results for a client with a history of atherosclerosis and notes elevated cholesterol levels. Which statement by the client indicates the nurse should plan follow-up instruction on a low-cholesterol diet?
- A. ''I take an omega-3 supplement daily.''
- B. ''I cook my food with canola oil.''
- C. ''I eat three eggs for breakfast each morning.''
- D. ''I flavor my meat with lemon juice.''
Correct Answer: C
Rationale: The correct answer is C. Eating three eggs daily increases cholesterol intake, which could exacerbate atherosclerosis. Omega-3 supplements, cooking with canola oil, and flavoring meat with lemon juice do not significantly impact cholesterol levels compared to consuming three eggs daily. Therefore, the nurse should focus on educating the client to reduce egg consumption to improve cholesterol levels.
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Three major causes of atherosclerosis are:
- A. Hyperthyroidism, underweight, and poor appetite
- B. High blood cholesterol, high blood pressure, and cigarette smoking
- C. Constipation, peptic ulcer disease, and pancreatitis
- D. Kidney failure, edema, and sodium retention
Correct Answer: B
Rationale: Atherosclerosis is primarily caused by high blood cholesterol, high blood pressure, and cigarette smoking. These factors contribute to the buildup of plaque in the arteries. Choices A, C, and D are incorrect. Hyperthyroidism, underweight, and poor appetite do not directly cause atherosclerosis. Similarly, constipation, peptic ulcer disease, pancreatitis, kidney failure, edema, and sodium retention are not among the primary causes of atherosclerosis.
Which nursing action(s) can result in disciplinary action by state boards of nursing?
- A. Release of client health information to a client's neighbor
- B. Delegation of a dressing change to unlicensed assistive personnel (UAP)
- C. Release of client health information to the client's durable power of attorney
- D. A, B
Correct Answer: D
Rationale: The correct answer is D. Disclosing client health information to unauthorized individuals like a client's neighbor (A) and improper delegation of tasks to unlicensed personnel (B) are serious violations of patient confidentiality and safety standards, which can lead to disciplinary action by state boards of nursing. Choice C, releasing client health information to the client's durable power of attorney, is not a violation as it involves sharing information with an authorized individual. Therefore, choices A and B are incorrect, making D the correct answer.
The nurse teaches the mother of an infant how to care for her infant following repair of a cleft lip. It is MOST important for the nurse to include which of the following instructions?
- A. Feed the infant with a newborn nipple while holding him in the recumbent position
- B. Clean the suture site with a cotton-tipped swab soaked in Betadine
- C. Place the infant in the prone position after feeding
- D. Feed the infant with a rubber-tipped syringe and burp frequently
Correct Answer: D
Rationale: The correct answer is D because feeding the infant with a rubber-tipped syringe reduces the risk of injury to the surgical site and prevents aspiration. Choice A is incorrect because feeding in the recumbent position can increase the risk of aspiration. Choice B is incorrect as Betadine is not recommended for wound care near the mouth due to its potential toxicity if ingested. Choice C is incorrect because placing the infant in the prone position after feeding can increase the risk of regurgitation and aspiration.
A 31-year-old client is seeking contraceptive information. Before responding to the client's questions about contraceptives, the nurse obtains a health history. What factor in the client's history indicates to the nurse that oral contraceptives are contraindicated?
- A. More than 30 years of age
- B. Had two multiple pregnancies
- C. Smokes 1 pack of cigarettes a day
- D. Has a history of borderline hypertension
Correct Answer: C
Rationale: The correct answer is C. Smoking, especially in clients over 30, increases the risk of thromboembolic events, making oral contraceptives contraindicated. Choice A is incorrect as age alone is not a contraindication for oral contraceptives. Choice B is incorrect as having multiple pregnancies is not a contraindication for oral contraceptives. Choice D is incorrect as borderline hypertension is not a strict contraindication for oral contraceptives.
What is the combat health support system in the field designed to do?
- A. Provide evacuation to the far rear for treatment and delay return to duty
- B. Project, sustain, and protect the health of the soldier in war and operations other than war
- C. Provide rearward evacuation and reassignment
- D. Provide far rear area care and delayed return to duty
Correct Answer: B
Rationale: The correct answer is B. The combat health support system in the field is designed to project, sustain, and protect the health of soldiers in both war and operations other than war. Choice A is incorrect because the system is not primarily focused on providing evacuation to the far rear for treatment, but rather on overall health support. Choice C is incorrect as it only mentions rearward evacuation and reassignment, which is a limited scope compared to the comprehensive support provided by the system. Choice D is incorrect as it narrowly focuses on far rear area care and delayed return to duty, missing the broader aspects of health support and protection.