A nursing intervention for anemia is:
- A. Medical therapy
- B. High protein, vitamin and iron diet
- C. Fluid therapy
- D. Chemotherapy
Correct Answer: B
Rationale: The correct answer is B, a high protein, vitamin, and iron diet, as it directly addresses the nutritional deficiencies associated with anemia. Proteins aid in the production of red blood cells, while iron and vitamins are essential for hemoglobin synthesis. Medical therapy (A) typically involves medications or blood transfusions, not dietary changes. Fluid therapy (C) may be used for certain types of anemia, but it is not a primary intervention. Chemotherapy (D) is not indicated for the treatment of anemia, as it is used for cancer treatment. Therefore, choice B is the most appropriate intervention for anemia.
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In giving health instructions, the nurse should infrom the client about the risk fsctors associated with coronary artery disease. Which of the following controllable risk factors is closely linked to the development of MI?
- A. Age
- B. high cholesterol levels
- C. medication usage
- D. gender
Correct Answer: B
Rationale: Step 1: High cholesterol levels contribute to the buildup of plaque in arteries, leading to atherosclerosis and increasing the risk of coronary artery disease.
Step 2: Atherosclerosis can result in a blockage of blood flow to the heart, causing a myocardial infarction (MI).
Step 3: Age is a risk factor for CAD but not directly linked to MI development.
Step 4: Medication usage may impact risk factors but is not a direct cause of MI.
Step 5: Gender can influence risk but is not the primary factor in MI development.
Which of the ff information should the nurse provide to clients who are prescribed rifampin?
- A. Take medication with meals
- B. Inform that contact lenses, if worn, may
- C. Avoid wearing glasses become colored
- D. Avoid tuna, aged cheese, and red wine
Correct Answer: B
Rationale: The correct answer is B because rifampin can cause discoloration of bodily fluids, including tears. If clients wear contact lenses, they need to be informed that the lenses may become colored due to this medication. This is important for the client's awareness and to prevent any potential harm to their eyes.
A: Taking medication with meals is not necessary for rifampin administration.
C: Avoiding wearing glasses is not relevant to rifampin treatment.
D: Avoiding tuna, aged cheese, and red wine is not specifically related to rifampin use.
A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which “related-to” phrase should the nurse add?
- A. Related to bone demineralization resulting in pathologic fractures
- B. Related to exhaustion secondary to an accelerated metabolic rate
- C. Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces
- D. Related to tetany secondary to a decreased serum calcium level
Correct Answer: A
Rationale: The correct answer is A: Related to bone demineralization resulting in pathologic fractures. In chronic hyperparathyroidism, there is excessive release of parathyroid hormone, leading to increased bone resorption and calcium release from bones, causing bone demineralization and weakening. This puts the client at risk for pathologic fractures. Choice B is incorrect because exhaustion is not a direct consequence of chronic hyperparathyroidism. Choice C is incorrect as edema and dry skin are not typical manifestations of hyperparathyroidism. Choice D is incorrect because tetany is more commonly associated with hypocalcemia, which is not a typical finding in hyperparathyroidism.
The nurse will monitor J.E. for the following signs and symptoms:
- A. Change in the levei of consciousness, tachypnea, tachycardia, petechiae
- B. Onset of chest pain, tachycardia, diaphoresis, nausea and vomiting
- C. Loss of consciousness, bradycardia, petechiae, and severe leg pain
- D. Change in leve! of consciousness, bradycardia, chest pain and oliguria
Correct Answer: A
Rationale: The correct answer is A.
1. Change in level of consciousness is crucial in assessing neurological status.
2. Tachypnea indicates possible respiratory distress or oxygenation issues.
3. Tachycardia may suggest a cardiovascular problem or inadequate perfusion.
4. Petechiae can be a sign of bleeding disorders or sepsis.
Option B is incorrect because chest pain, diaphoresis, and nausea/vomiting are more indicative of a cardiac event rather than monitoring for J.E.'s signs and symptoms.
Option C is incorrect because loss of consciousness, bradycardia, and leg pain do not align with the signs and symptoms to monitor for J.E.
Option D is incorrect because bradycardia, chest pain, and oliguria are not as comprehensive as the signs and symptoms listed in option A for monitoring J.E.
What are the essential nursing actions that should be taken for a client with immune system disorder? Choose all that apply
- A. Follow agency guidelines to control
- B. Review drug references
- C. Advise the client on modifying the
- D. Monitor client for depression home environment
Correct Answer: E
Rationale: The correct answer is missing from the choices provided. However, for a client with an immune system disorder, essential nursing actions include:
E: Educate the client on the importance of maintaining a healthy lifestyle, avoiding exposure to infections, and adhering to prescribed medications. This is crucial for managing the immune system disorder effectively.
Incorrect choices:
A: Following agency guidelines is important but doesn't specifically address the client's immune system disorder.
B: Reviewing drug references may be necessary but is not a priority in managing the immune system disorder.
C: Advising the client on modifying the home environment is not directly related to managing the immune system disorder.
D: Monitoring the client for depression is important but not specific to addressing the immune system disorder.