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A patient was diagnosed with hiatal hernia. She frequently has regurgitation and a sour taste on his mouth especially after eating large meals. Which action by the client shows understanding of her treatment regimen?
- A. elevate her legs when she is sleeping
- B. drink more fluids with her meals
- C. increase the roughage in her diet
- D. avoid caffeine, alcohol, and chocolate
Correct Answer: D
Rationale: The correct answer is D: avoid caffeine, alcohol, and chocolate. This helps to reduce acid reflux symptoms associated with hiatal hernia. Caffeine, alcohol, and chocolate can relax the lower esophageal sphincter, leading to increased reflux. Elevating legs (choice A) does not address the underlying issue. Drinking more fluids (choice B) can exacerbate symptoms by increasing stomach volume. Increasing roughage (choice C) may worsen symptoms due to increased gastric distension. By avoiding triggers like caffeine, alcohol, and chocolate, the client can effectively manage her symptoms.
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Nurse Raymond is giving instructions to an elderly client on diabetic foot care. Which teaching is not part of foot care?
- A. wear comfortable shoes that fit well and protect your feet
- B. trim your toenails straight across and file edges with emery board
- C. wash your feet in hot water to keep feet soft
- D. wear shoes at the beach or on hot pavement
Correct Answer: C
Rationale: The correct answer is C because washing feet in hot water can lead to burns or skin damage for those with diabetes. A: Proper footwear is essential for preventing foot injuries. B: Trimming toenails straight across helps prevent ingrown nails. D: Wearing shoes on hot surfaces prevents burns or blisters. Overall, C is incorrect due to the potential harm it can cause to diabetic feet.
During the evaluation phase, what key action does the nurse perform?
- A. Diagnose the client’s condition based on new information.
- B. Identify nursing interventions for client care.
- C. Determine the effectiveness of the care plan.
- D. Develop goals and outcomes for client care.
Correct Answer: C
Rationale: During the evaluation phase, the nurse performs the key action of determining the effectiveness of the care plan. This involves assessing whether the client's goals are being met, if interventions are achieving the desired outcomes, and if any modifications are necessary. This step is crucial to ensure the care plan is successful and the client's needs are being addressed appropriately.
Choice A is incorrect because diagnosing the client's condition is typically done in the assessment phase, not during evaluation. Choice B is incorrect as identifying nursing interventions is part of the planning phase. Choice D is incorrect as developing goals and outcomes is part of the planning phase as well. Overall, the evaluation phase focuses on assessing the effectiveness of the care plan rather than diagnosing, identifying interventions, or developing goals.
The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for?
- A. Actinic
- B. Arcus
- C. Asymmetry
- D. Assessment
Correct Answer: C
Rationale: The correct answer is C: Asymmetry. The ABCD method is a mnemonic used for assessing skin lesions for possible skin cancer. The A in ABCD stands for Asymmetry, indicating that the lesion is not symmetrical in shape or color. Skin cancers often exhibit asymmetrical features. Actinic (Choice A) refers to sun damage, Arcus (Choice B) is a term related to the eye, and Assessment (Choice D) is a general term that does not specifically relate to skin lesion evaluation. By focusing on asymmetry, healthcare providers can identify potential skin cancer lesions early for further evaluation and treatment.
A nurse writes the following nursing diagnosis for a client with Alzheimer’s disease: 'Disturbed Thought Processes related to Alzheimer’s disease as evidenced by incoherent language.' Which part of this diagnosis is considered the problem statement?
- A. Disturbed thought processes
- B. Related to
- C. Alzheimer’s disease
- D. Incoherent language
Correct Answer: A
Rationale: The correct answer is A: Disturbed thought processes. This is the problem statement because it identifies the specific nursing diagnosis that reflects the client's cognitive impairment. "Disturbed thought processes" directly addresses the issue the nurse is observing in the client. The other choices are not the problem statement. "Related to" is the etiology or cause of the problem, "Alzheimer’s disease" is the medical condition, and "Incoherent language" is the defining characteristic or evidence of the problem. Therefore, A is the correct answer as it clearly states the client's primary issue.
Which of the ff. conditions places a patient at risk for respiratory complications following his splenectomy?
- A. A low platelet count
- B. Early ambulation
- C. An incision near the diaphragm
- D. Early discharge
Correct Answer: C
Rationale: The correct answer is C: An incision near the diaphragm. Following a splenectomy, an incision near the diaphragm can lead to respiratory complications due to potential irritation or injury to the diaphragm. This can result in impaired breathing and increased risk of respiratory issues such as pneumonia.
A: A low platelet count is not directly related to respiratory complications following a splenectomy.
B: Early ambulation is generally encouraged to prevent complications such as blood clots but does not specifically impact respiratory complications.
D: Early discharge may not directly lead to respiratory complications, as long as the patient is adequately monitored postoperatively.