Nokea
An adult is on a clear liquid diet. Which food item can be offered/
- A. Milk
- B. Orange juice
- C. Jello
- D. Ice cream
Correct Answer: C
Rationale: The correct answer is C: Jello. A clear liquid diet includes transparent liquids that do not contain any solid particles, providing easily digestible nutrients. Jello meets these criteria as it is a clear, gelatin-based dessert that melts into a liquid form at room temperature.
Rationale:
1. Jello is a clear liquid that does not contain solid particles, making it suitable for a clear liquid diet.
2. Milk (A) and ice cream (D) are not considered clear liquids as they contain fats and proteins, which are not allowed on a clear liquid diet.
3. Orange juice (B) contains pulp and fibers, making it unsuitable for a clear liquid diet.
Summary:
Jello is the correct choice because it meets the criteria of being a clear liquid without solid particles. Milk, orange juice, and ice cream are not appropriate choices for a clear liquid diet due to their composition.
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Mr. Reyea has expressive aphasia. As a part of a long range planning. The nurse should ;
- A. Provide positive feedback when he uses the word correctly
- B. Wait for him to verbally state needs regardless of how long it may take
- C. Suggest that he get help at home because the disability is permanent
- D. Help the family to accept the fact that Mr, Reyes cannot participate in verbal communication Situation - Patricia Zeno is a client with history myasthenia gravis
Correct Answer: A
Rationale: The correct answer is A: Provide positive feedback when he uses the word correctly. In individuals with expressive aphasia, positive reinforcement helps improve communication skills. Praising Mr. Reyea when he uses words correctly encourages continued effort and boosts confidence. This approach motivates him to communicate more despite his challenges.
Summary of other choices:
B: Waiting indefinitely for Mr. Reyea to verbally state needs is not practical and may lead to frustration.
C: Suggesting permanent help at home assumes the disability cannot improve, which is not necessarily true for expressive aphasia.
D: Helping the family to accept Mr. Reyea's inability to communicate verbally may hinder his progress and limit his social interactions.
Which of the following hormones retains sodium in the body?
- A. Antidiuretic hormone
- B. Aldosterone
- C. Thyroid hormone
- D. Insulin
Correct Answer: B
Rationale: The correct answer is B: Aldosterone. Aldosterone is a hormone produced by the adrenal glands that helps regulate sodium and water balance in the body. It acts on the kidneys to increase reabsorption of sodium, leading to water retention and increased blood volume. This helps maintain blood pressure and electrolyte balance.
A: Antidiuretic hormone (ADH) mainly acts on the kidneys to increase water reabsorption, not sodium retention.
C: Thyroid hormone does not directly influence sodium retention.
D: Insulin regulates blood sugar levels by promoting glucose uptake, it does not have a direct role in sodium retention.
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
- A. Complete the questions in chronological order.
- B. Focus on the patient’s presenting situation.
- C. Make accurate interpretations of the data.
- D. Conduct an observational overview.
Correct Answer: B
Rationale: The correct answer is B - Focus on the patient's presenting situation. This is because in the problem-oriented approach, the nurse must first gather data related to the patient's current issue or concern. This initial focus helps in identifying the primary problem, setting priorities, and developing a care plan.
Now, let's analyze the other choices:
A: Completing questions in chronological order may not be necessary or relevant to addressing the patient's immediate issue.
C: Making accurate interpretations of the data comes after data collection, so it is not the first step.
D: Conducting an observational overview is important but should come after focusing on the patient's presenting situation to gather specific and relevant data.
A 50-year old male was brought toi the emergency department with a diagnosis of diabetes insipidus. The client had a posterior pituitary tumor. The nursing diagnosis most appropriate for this client is:
- A. fluid volume excess
- B. incontinence, bowel
- C. fluid volume deficit
- D. diarrhea
Correct Answer: C
Rationale: The correct answer is C: fluid volume deficit. In diabetes insipidus, there is an excessive amount of dilute urine excreted, leading to dehydration and fluid volume deficit. The posterior pituitary tumor causes a deficiency in antidiuretic hormone (ADH), which regulates water reabsorption in the kidneys. As a result, the client experiences polyuria and polydipsia, leading to fluid volume deficit. Choices A, B, and D are incorrect because diabetes insipidus does not cause fluid volume excess, incontinence, or diarrhea. The key is to recognize the pathophysiology of diabetes insipidus and its impact on fluid balance.
The nurse knows which of the following is true about immunity?
- A. Antibody-mediated defense occurs through the T-cell system
- B. Cellular immunity is mediated by antibodies produced by the B-cells
- C. Antibodies are produced by the B-cells
- D. Lymphocytes increase with an allergic response
Correct Answer: C
Rationale: Rationale:
Choice C is correct because antibodies are indeed produced by B-cells as part of the adaptive immune response. B-cells differentiate into plasma cells that produce antibodies to target specific antigens. This process is essential for generating immunity against pathogens.
Incorrect Choices:
A: Antibody-mediated defense occurs through the B-cell system, not the T-cell system. T-cells are involved in cell-mediated immunity.
B: Cellular immunity is mediated by T-cells, not antibodies produced by B-cells. T-cells directly attack infected cells.
D: Lymphocytes can increase during an allergic response, but this does not specifically relate to immunity through antibody production by B-cells.