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A patient with deep vein thrombosis (DVT) is prescribed warfarin. Which dietary instruction should the nurse provide?
- A. Avoid foods high in vitamin K.
- B. Increase intake of dairy products.
- C. Limit intake of citrus fruits.
- D. Avoid high-sodium foods.
Correct Answer: A
Rationale: The correct answer is A: Avoid foods high in vitamin K. Warfarin is a vitamin K antagonist, so consuming high-vitamin K foods can counteract its effects. By avoiding such foods, the medication can work effectively in preventing further blood clot formation. Choice B is incorrect because dairy products do not directly interact with warfarin. Choice C is incorrect as citrus fruits do not have a significant impact on warfarin therapy. Choice D is incorrect as sodium intake is not directly related to the action of warfarin.
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A patient is admitted with a diagnosis of myasthenia gravis. What symptom should the nurse expect to find during the assessment?
- A. Joint pain
- B. Muscle weakness
- C. Loss of sensation
- D. Severe headache
Correct Answer: B
Rationale: The correct answer is B: Muscle weakness. Myasthenia gravis is characterized by muscle weakness due to an autoimmune attack on acetylcholine receptors at the neuromuscular junction. This leads to impaired muscle contraction and weakness, especially in the face, neck, and extremities. Joint pain (A) is not a typical symptom of myasthenia gravis. Loss of sensation (C) is more indicative of a sensory nerve disorder rather than a motor disorder like myasthenia gravis. Severe headache (D) is not a common symptom of myasthenia gravis; it is more likely to be associated with other conditions such as migraines or intracranial pathology.
What side effect should be monitored for in a patient with chronic heart failure taking spironolactone?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypernatremia
Correct Answer: B
Rationale: The correct answer is B: Hyperkalemia. Spironolactone is a potassium-sparing diuretic commonly used in patients with heart failure. It works by blocking the aldosterone receptor, leading to potassium retention and potential hyperkalemia. Monitoring potassium levels is crucial as hyperkalemia can increase the risk of arrhythmias and other cardiac complications in heart failure patients.
A: Hypokalemia is incorrect because spironolactone typically causes potassium retention.
C: Hyponatremia and D: Hypernatremia are incorrect as spironolactone does not directly affect sodium levels.
In summary, monitoring for hyperkalemia is essential in patients with heart failure taking spironolactone to prevent adverse cardiac events.
What skin care instructions should the nurse give to a patient receiving external beam radiation therapy for cancer treatment?
- A. Use a heating pad to relieve any pain in the treated area.
- B. Apply alcohol-based lotions to the treated area daily.
- C. Avoid exposing the treated area to sunlight.
- D. Wash the treated area with hot water and strong soap.
Correct Answer: C
Rationale: The correct answer is C: Avoid exposing the treated area to sunlight. This is important because radiation therapy can make the skin more sensitive to sunlight, leading to increased risk of sunburn and skin damage. Sun exposure can worsen skin reactions and delay healing. Choice A is incorrect because heat sources like heating pads can exacerbate skin irritation. Choice B is incorrect as alcohol-based lotions can further irritate the skin. Choice D is incorrect as hot water and strong soap can be too harsh on the sensitive skin. Overall, protecting the treated area from sunlight is crucial for optimal skin care during radiation therapy.
When providing dietary instructions to a client with cirrhosis, which dietary restriction is important for the nurse to emphasize?
- A. Low-protein diet
- B. Low-sodium diet
- C. High-fiber diet
- D. High-calcium diet
Correct Answer: B
Rationale: Rationale: Correct answer is B (Low-sodium diet) for cirrhosis because sodium can worsen fluid retention and increase ascites. A (Low-protein diet) is not necessary unless hepatic encephalopathy is present. C (High-fiber diet) can help with constipation but not a primary concern. D (High-calcium diet) is not a priority for cirrhosis management.
A patient with a myocardial infarction (MI) is being treated with intravenous morphine. What is the primary reason for administering morphine to this patient?
- A. To reduce pain.
- B. To decrease anxiety.
- C. To reduce cardiac workload.
- D. To increase respiratory rate.
Correct Answer: C
Rationale: The primary reason for administering morphine to a patient with MI is to reduce cardiac workload. Morphine acts as a vasodilator and decreases preload and afterload on the heart, reducing myocardial oxygen demand. This helps to improve coronary blood flow and decrease the workload on the heart muscle, which is crucial in the setting of an MI.
Explanation for other choices:
A: While morphine can help reduce pain in MI, the primary reason for administering it is to reduce cardiac workload.
B: Morphine may have a calming effect, but the primary goal is to reduce cardiac workload.
D: Morphine can actually decrease respiratory rate as a side effect, making this choice incorrect.