Nokea
After obtaining a nutritional assessment of an elderly client, the nurse determines that the client's diet lacks sufficient protein. Which foods represent low-cost sources of protein?
- A. Potatoes and beef
- B. Peas and beans
- C. Tomatoes and beets
- D. Pork and rice
Correct Answer: B
Rationale: Peas and beans are low-cost, high-protein foods. Beef and pork are expensive, and potatoes, tomatoes, beets, and rice are low in protein.
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A client is receiving Vincristine (Marqibo). The client should be taught that the medication can:
- A. Cause diarrhea
- B. Change the color of her urine
- C. Cause mental confusion
- D. Cause changes in taste
Correct Answer: C
Rationale: Vincristine can cause neurotoxicity, including mental confusion. Diarrhea, urine color changes, and taste alterations are less common.
The nurse is caring for a 10-year-old client with osteomyelitis. Which of the following actions should the nurse take to promote age-appropriate growth and development during hospitalization?
- A. Ask the parent to bring schoolwork for the client to complete
- B. Encourage the client to engage in imaginary play with animal puppets
- C. Explain procedures to the client immediately before they are performed
- D. Provide opportunities for the client to play independently
Correct Answer: A
Rationale: Schoolwork supports cognitive development for a 10-year-old. Imaginary play suits younger children, last-minute explanations increase anxiety, and independent play may not meet social needs.
The nurse is caring for an adult male who is receiving haloperidol (Haldol). Which complaint by the client is of most concern to the nurse and should be immediately reported?
- A. I have gained so much weight in the last few months.
- B. I am having trouble getting an erection.
- C. My legs are cramping and I feel like I need to walk all the time.
- D. It's really embarrassing. I'm drooling a lot.
Correct Answer: C
Rationale: Leg cramping and restlessness suggest akathisia, a serious extrapyramidal side effect of haloperidol, requiring immediate reporting.
Which one of the following symptoms is commonly reported in children with attention deficit hyperactive disorder?
- A. Difficulty sleeping at night
- B. Impulsivity
- C. Poor appetite
- D. Nonintentional tremor
Correct Answer: B
Rationale: Impulsivity is a hallmark symptom of ADHD, characterized by acting without forethought, often seen in children with the disorder.
What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?
- A. The disease will incubate longer and progress more slowly in this infant
- B. The infant is very susceptible to infections
- C. Growth and development patterns will proceed at a normal rate
- D. Careful monitoring of renal function is indicated
Correct Answer: B
Rationale: The infant is very susceptible to infections. HIV compromises the immune system, increasing susceptibility to opportunistic infections.