Nokea
As part of the client's discharge planning after a subtotal gastrectomy, the nurse has identified Imbalanced nutrition: Less than body requirements as a major nursing diagnosis. To help the client meet nutritional goals at home, the nurse should develop a plan of care that includes which of the following interventions?
- A. Instruct the client to increase the amount eaten at each meal.
- B. Encourage the client to eat smaller amounts more frequently.
- C. Explain that if vomiting occurs after a meal, nothing more should be eaten that day.
- D. Inform the client that bland foods are typically less nutritional and should be used minimally.
Correct Answer: B
Rationale: Smaller, frequent meals help prevent dumping syndrome and ensure adequate nutrition post-gastrectomy. Large meals, fasting after vomiting, or avoiding bland foods are not appropriate.
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A client had a mastectomy followed by chemotherapy 6 months ago. She reports that she is now 'unable to concentrate at her card game' and 'it seems harder and harder to finish her errands because of exhaustion.' Based on this information, the nurse should suggest that the client do which of the following?
- A. Take frequent naps.
- B. Limit activities.
- C. Increase fluid intake.
- D. Avoid contact with others.
Correct Answer: A
Rationale: The client's symptoms of difficulty concentrating and exhaustion suggest fatigue, which is a common long-term side effect of chemotherapy. Taking frequent naps can help manage fatigue by allowing the client to rest and conserve energy, improving her ability to perform daily activities. Limiting activities may be overly restrictive and not address the root issue, increasing fluid intake is not directly related to fatigue unless dehydration is present, and avoiding contact with others is unnecessary unless there is an infection risk.
A client with an ileal conduit has a rash around the stoma. The nurse should:
- A. Apply a antifungal cream.
- B. Clean with soap and water.
- C. Use a larger appliance.
- D. Cover with gauze.
Correct Answer: B
Rationale: Cleaning with soap and water removes irritants, promoting rash healing.
Which of the following factors would most likely contribute to the development of a client's hiatal hernia?
- A. Having a sedentary desk job.
- B. Being 5 feet, 3 inches tall and weighing 190 lb.
- C. Using laxatives frequently.
- D. Being 40 years old.
Correct Answer: B
Rationale: Obesity (e.g., 5'3†and 190 lb) increases intra-abdominal pressure, a major contributor to hiatal hernia development. The other factors are less directly related.
Initial treatment for a cerebrospinal fluid (CSF) leak after transsphenoidal hypophysectomy would most likely involve:
- A. Repacking the nose.
- B. Returning the client to surgery.
- C. Enforcing bed rest with the head of the bed elevated.
- D. Administering high-dose corticosteroid therapy.
Correct Answer: C
Rationale: Bed rest with head elevation reduces pressure on the surgical site, promoting healing of a CSF leak.
During an initial assessment of a client diagnosed with vasospastic disorder (Raynaud's phenomenon), the nurse notes a sudden color change to white in the fingers. The nurse should first assess:
- A. Appearance of cyanosis
- B. Radial pulse
- C. SpO2 of the affected fingers
- D. Blood pressure
Correct Answer: B
Rationale: A sudden color change to white in Raynaud's indicates vasospasm. Assessing the radial pulse first confirms whether blood flow is present despite the vasospasm, guiding further action. Cyanosis, SpO2, and blood pressure are secondary, as pulse assessment is more immediate and specific.