Nokea
An adult is being taught about a healthy diet. How can the food pyramid help guide the client on his diet?
- A. By indicating exactly how many servings of each group to eat
- B. By calculating how many calories the client should have
- C. By suggesting daily food choices
- D. By dividing the food into four basic groups
Correct Answer: C
Rationale: The food pyramid can help guide the client on his diet by suggesting daily food choices. The food pyramid categorizes different food groups based on their nutritional compositions and recommended daily servings. By following the food pyramid, the client can make informed choices about what types and amounts of food to consume each day to achieve a balanced and healthy diet. The visual representation of the food pyramid also helps in understanding the relative proportions of different food groups that are part of a nutritious diet.
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The client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for:
- A. exophthalmos and conjunctival redness
- B. flushed, warm, moist skin
- C. systolic murmur at the left sternal border
- D. decreased body temperature and cold intolerance
Correct Answer: D
Rationale: The correct assessment findings to stay alert for when evaluating for hypothyroidism are decreased body temperature and cold intolerance. Hypothyroidism is a condition characterized by an underactive thyroid gland, leading to a decrease in metabolic rate. This can result in symptoms such as feeling cold all the time and a lower body temperature. Therefore, the nurse should keep an eye out for these symptoms during the assessment of a client being evaluated for hypothyroidism. Symptoms such as exophthalmos and conjunctival redness are more commonly associated with hyperthyroidism.
Which of the following responses indicates sympathetic nervous system function?
- A. Tachycardia, dilated pupils
- B. Hypoglycaemia, headache
- C. Increased peristalsis, abdominal cramping
- D. Pupil constriction, bronchoconstriction
Correct Answer: A
Rationale: The sympathetic nervous system is responsible for the body's "fight or flight" response. Tachycardia (increased heart rate) and dilated pupils are classic responses of the sympathetic nervous system activation during times of stress or danger. These physiological responses prepare the body for action, such as running away from a threat.
What is the first action the nurse should take?
- A. Start an IV lines for fluids
- B. Get an ECG
- C. Place a Foley catheter
- D. Check for neurologic status
Correct Answer: D
Rationale: The first action the nurse should take is to check for neurologic status. This is essential in assessing the patient's level of consciousness, orientation, motor function, and pupil responses. It helps determine if the patient is experiencing neurological issues such as a stroke, which would require immediate medical attention. Checking neurologic status is a priority because it guides the nurse in identifying the next steps for the patient's care.
Antivenins should be considered in the treatment of all of the following EXCEPT
- A. rattlesnake envenomations
- B. scorpion envenomations
- C. black widow envenomations
- D. stonefish envenomations
Correct Answer: E
Rationale: Hymenoptera envenomations (e.g., bee stings) typically do not require antivenin, as they are managed with supportive care.
While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially?
- A. Activate the code blue or emergency system
- B. Do nothing because acrocyanosis is normal in the neonate
- C. Immediately take the newborn's temperature according to hospital policy
- D. Notify the physician of the need for a cardiac consult
Correct Answer: B
Rationale: Acrocyanosis is a normal finding in newborns, characterized by bluish discoloration of the hands and feet due to immature circulation. It usually resolves on its own within 24 hours after birth and does not require any intervention. It is essential for the nurse to recognize this normal physiological process to avoid unnecessary interventions. Activating the code blue system, taking the newborn's temperature immediately, or notifying the physician of the need for a cardiac consult is not indicated in this scenario because acrocyanosis is a benign condition in neonates.