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An adult is being discharged on a low-sodium, low-fat diet. Which menu, if selected by the client, indicates an understanding of the diet?
- A. Hamburger with fries, apple pie, milkshake
- B. Tossed salad with vinaigrette dressing, baked skinny chicken, applesauce
- C. Steak, corn on the cob, fruit salad
- D. Fried shrimp, coleslaw, strawberry shortcake
Correct Answer: B
Rationale: Tossed salad, baked skinless chicken, and applesauce are low in sodium and fat, aligning with the prescribed diet.
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An elderly war veteran with prostate cancer and coronary artery disease is hospitalized for urosepsis. The client becomes angry with one of the unlicensed assistive personnel (UAP) who is trying to help the client bathe. Later, the UAP expresses frustration with the client to the nurse. Which statement would be the most appropriate response?
- A. I’ll talk with the client to see why the client is angry
- B. It sounds like you shouldn’t work with this client, so I will reassign you
- C. Let’s go together to ask about the client’s concerns
- D. Why don’t you go talk with the client about why the client is angry?
Correct Answer: C
Rationale: Going together to address concerns promotes teamwork, de-escalates conflict, and ensures the client’s needs are met. Individual talks risk miscommunication, and reassignment avoids resolution.
The nurse is caring for a client with Grave's disease. Which finding would indicate a complication of the client's disease?
- A. Extreme fatigue
- B. Increased heart rate
- C. Shortness of breath
- D. Urinary frequency
Correct Answer: C
Rationale: Shortness of breath may indicate thyroid storm, a life-threatening complication of Grave's disease. Fatigue and increased heart rate are common symptoms, and urinary frequency is unrelated.
A young woman has routine blood work done at her prenatal appointment. The results indicate that she has a hemoglobin level of 10 g/dL. The nurse explains to her that this result is:
- A. high.
- B. insignificant.
- C. low.
- D. normal.
Correct Answer: C
Rationale: A hemoglobin of 10 g/dL is low (normal in pregnancy: 11-12 g/dL), indicating possible anemia, requiring further evaluation.
A 3-year-old child had a seizure two days ago when the child's temperature was 105°F. The child has had no previous seizures. Today, the parent and the child are in the physician's office. What should the nurse include when teaching the parent?
- A. The child now has epilepsy and will need long-term care for this condition.
- B. If the child develops a fever over 101°F, administer ibuprofen.
- C. Make sure the child drinks plenty of water every day.
- D. Call the physician's office immediately if the child develops a temperature over 100.4°F.
Correct Answer: B
Rationale: A febrile seizure at 105°F in a 3-year-old without prior seizures suggests a one-time event; ibuprofen for fevers above 101°F helps prevent recurrence, while epilepsy or immediate reporting is premature.
The nurse is caring for a 2-year-old who had an anaphylactic reaction to a bee sting. After the nurse reinforces teaching on applying epinephrine, which statements by the parent indicate correct understanding? Select all that apply.
- A. I will give the injection if my child has trouble breathing after a bee sting
- B. I will give the injection in the upper arm
- C. I will keep an epinephrine injection close to my child at all times
- D. I will take my child to the emergency room after giving the injection
- E. The injection can be given through clothing
Correct Answer: A,C,D,E
Rationale: Epinephrine is given for breathing difficulty, kept accessible, followed by ER visit, and can be administered through clothing. The correct site is the thigh, not the upper arm, making B incorrect.