Nokea
A patient with abnormal sodium losses is receiving a house diet. To provide 1,600mg sodium daily, the nurse could supplement the patient’s diet with:
- A. One beef cube and 8oz of tomato juice
- B. One beef cube and 16oz of tomato juice
- C. Four beef cubes and 8oz of tomato juice
- D. One beef cube and 12oz tomato juice
Correct Answer: D
Rationale: The correct answer is D because 1 beef cube contains about 1,000mg of sodium. To reach 1,600mg, the patient needs an additional 600mg. 12oz of tomato juice contains approximately 600mg of sodium, making it the right choice.
A: Not enough sodium from the beef cube and tomato juice.
B: Too much sodium from the 16oz of tomato juice.
C: Too much sodium from the 4 beef cubes.
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While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?
- A. Consider cultural differences during this assessment.
- B. Ask the patient to make eye contact to determine her affect.
- C. Continue with the interview and document that the patient is depressed.
- D. Notify the health care provider to recommend a psychological evaluation.
Correct Answer: A
Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect and humility, especially when speaking to authority figures. By being aware of this cultural norm, the nurse can avoid misinterpreting the patient's behavior as a sign of depression or dishonesty. Asking the patient to make eye contact (choice B) may make the patient uncomfortable and disrupt the therapeutic relationship. Continuing with the interview and documenting depression (choice C) without considering cultural differences can lead to inaccurate assessment and inappropriate interventions. Notifying the health care provider for a psychological evaluation (choice D) is premature and unnecessary without first understanding the cultural context of the patient's behavior.
A nurse changes a client’s wound dressing according to the protocol outlined by the health care agency. What type of nursing intervention is this?
- A. Independent intervention
- B. Dependent intervention
- C. Interdependent intervention
- D. Collaborative intervention
Correct Answer: C
Rationale: The correct answer is C: Interdependent intervention. This type of nursing intervention involves collaboration with other healthcare professionals to provide holistic care. In this scenario, the nurse is following a protocol set by the health care agency, which likely involves input and guidance from various team members. The nurse's actions require coordination and communication with others to ensure the best outcome for the client.
Choice A (Independent intervention) would involve actions that the nurse can perform autonomously without requiring direction from others. Choice B (Dependent intervention) would require an order or prescription from a healthcare provider for the nurse to carry out. Choice D (Collaborative intervention) involves working together with other healthcare professionals on a specific aspect of care, but in this case, the nurse is primarily following a set protocol without necessarily actively collaborating with others during the task.
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that would most support the nurse’s analysis are:
- A. Rise in blood pressure and heart rate
- B. Rise in blood pressure and drop in heart rate
- C. Drop in blood pressure and rise in heart rate
- D. none of the above
Correct Answer: C
Rationale: The correct answer is C: Drop in blood pressure and rise in heart rate. After a splenectomy, the client is at risk for orthostatic hypotension due to decreased blood volume. A drop in blood pressure and a compensatory rise in heart rate are common orthostatic changes. This occurs because the body tries to maintain perfusion to vital organs. A rise in blood pressure and heart rate (Choice A) would not align with orthostatic changes. A rise in blood pressure and drop in heart rate (Choice B) is contradictory to the body's compensatory response to maintain perfusion. Therefore, the most supportive vital sign values for abnormal orthostatic changes in this client would be a drop in blood pressure and a rise in heart rate.
The nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend:
- A. increasing saturated fat intake and fasting in the afternoon.
- B. increasing intake of vitamins B and D and taking iron supplements.
- C. eating a candy bar if light-headedness occurs.
- D. consuming a low-carbohydrate, high-protein diet and avoiding fasting.
Correct Answer: D
Rationale: The correct answer is D because a low-carbohydrate, high-protein diet helps stabilize blood sugar levels and prevents hypoglycemic episodes. Carbohydrates cause rapid spikes and drops in blood sugar, while protein helps maintain stable levels. Avoiding fasting also helps regulate blood sugar. Choice A is incorrect as increasing saturated fat and fasting can worsen hypoglycemia. Choice B is incorrect as vitamins and iron do not directly address hypoglycemia. Choice C is incorrect as relying on sugary foods like candy bars can lead to further blood sugar imbalances.
While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?
- A. Consider cultural differences during this assessment.
- B. Ask the patient to make eye contact to determine her affect.
- C. Continue with the interview and document that the patient is depressed.
- D. Notify the health care provider to recommend a psychological evaluation.
Correct Answer: A
Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect, humility, or shyness, rather than an indication of depression or dishonesty. By understanding and respecting cultural norms, the nurse can build rapport and trust with the patient. This approach promotes effective communication and a positive patient-provider relationship.
Option B is incorrect because forcing the patient to make eye contact may make her uncomfortable and hinder the therapeutic relationship. Option C is incorrect because assuming the patient is depressed based on cultural differences is inappropriate and may lead to misdiagnosis. Option D is incorrect because jumping to recommendations for a psychological evaluation without considering cultural differences first can be stigmatizing and unnecessary.