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 and foods that are liquid at room temperature. Jello meets this criteria as it is a clear, easily digestible food. Milk (A) is not allowed on a clear liquid diet due to its opaque nature. Orange juice (B) contains pulp and is not considered clear. Ice cream (D) is a solid food and not permitted on a clear liquid diet. Therefore, Jello is the most suitable option for someone on a clear liquid diet.
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Which of the ff nursing interventions is involved when caring for a client with influenza?
- A. Maintaining airborne transmission
- B. Oxygen administration
- C. Immediate recognition of respiratory
- D. Complete bed rest distress
Correct Answer: C
Rationale: The correct answer is C: Immediate recognition of respiratory distress. This is crucial when caring for a client with influenza as the virus can lead to respiratory complications. Prompt recognition allows for timely intervention and prevents further deterioration.
A: Maintaining airborne transmission is incorrect as the goal is to prevent the spread of influenza through droplet precautions, not airborne transmission.
B: Oxygen administration may be necessary for severe cases of influenza, but immediate recognition of respiratory distress takes precedence in the nursing interventions.
D: Complete bed rest is not recommended for influenza as mobilization and deep breathing exercises are important to prevent complications like pneumonia.
As part of primary cancer prevention program, an oncology nurse answers questions from the public at health fair. When someone asks about the laryngeal cancer, the nurse should explain that:
- A. Laryngeal cancer is one of the most preventable types of cancer
- B. Inhaling polluted air isn’t a risk factor for laryngeal cancer
- C. Laryngeal cancer occurs primarily in women
- D. Adenocarcinoma accounts for most cases of laryngeal cancer
Correct Answer: A
Rationale: The correct answer is A: Laryngeal cancer is one of the most preventable types of cancer. This is because the primary risk factors for laryngeal cancer are largely related to lifestyle choices such as smoking, excessive alcohol consumption, and exposure to certain occupational hazards. By avoiding these risk factors, individuals can significantly reduce their chances of developing laryngeal cancer.
Choices B, C, and D are incorrect:
B: Inhaling polluted air isn’t a risk factor for laryngeal cancer - This is incorrect as exposure to polluted air can contribute to the development of laryngeal cancer.
C: Laryngeal cancer occurs primarily in women - This is incorrect as laryngeal cancer occurs more frequently in men than in women.
D: Adenocarcinoma accounts for most cases of laryngeal cancer - This is incorrect as squamous cell carcinoma is the most common type of laryngeal cancer, not adenocarcin
A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which initial action will the nurse take next to revise the plan of care?
- A. Consult physical therapy.
- B. Establish a new plan of care.
- C. Set new priorities for the patient.
- D. Assess the patient.
Correct Answer: D
Rationale: The correct initial action to take after the patient falls is to assess the patient (Choice D). This is important to determine the extent of any injuries sustained, assess the patient's current condition, and identify any factors that may have contributed to the fall. By conducting a thorough assessment, the nurse can gather crucial information to inform the revision of the care plan. Consulting physical therapy (Choice A) may be necessary later on but is not the immediate priority. Establishing a new plan of care (Choice B) and setting new priorities (Choice C) should be based on the assessment findings, making Choice D the most appropriate initial action.
Clients with myastherda gravis, Guillain - Barre Syndrome or amyothrophic sclerosis experience:
- A. Progressive deterioration until death
- B. Deficiencies of essential neurotransmitter
- C. Increased risk of respiratory complications
- D. Involuntary twitching of small muscle group
Correct Answer: C
Rationale: The correct answer is C: Increased risk of respiratory complications. Clients with myasthenia gravis, Guillain-Barre Syndrome, or amyotrophic lateral sclerosis may experience respiratory muscle weakness, leading to difficulty breathing and an increased risk of respiratory complications such as pneumonia or respiratory failure. This is due to the involvement of the muscles responsible for breathing in these conditions. Progressive deterioration until death (A) is not always the case and varies depending on the condition and individual. Deficiencies of essential neurotransmitters (B) is not a common symptom in these conditions. Involuntary twitching of small muscle groups (D) is not a characteristic symptom of these neurological disorders.
What is an example of a nurse modifying the care plan during the evaluation phase?
- A. Adding a new intervention to address an unmet goal.
- B. Performing routine monitoring of the client’s condition.
- C. Administering medication as prescribed by the physician.
- D. Completing discharge paperwork for the client.
Correct Answer: A
Rationale: The correct answer is A because modifying the care plan during the evaluation phase involves making changes based on the client's response to interventions. By adding a new intervention to address an unmet goal, the nurse demonstrates critical thinking and adaptability in response to the client's needs. This action shows that the nurse is actively assessing and revising the care plan to ensure it is effective in meeting the client's goals.
Choice B is incorrect because routine monitoring is part of the assessment and implementation phases, not specifically related to modifying the care plan during evaluation. Choice C is incorrect as administering medication is part of the implementation phase and does not necessarily involve modifying the care plan. Choice D is also incorrect as completing discharge paperwork is typically part of the discharge planning phase, not the evaluation phase where modifications to the care plan are made based on client outcomes.