Nokea
At a health-screening clinic, an adult male client's total plasma cholesterol level is 200 mg/dL. The nurse should
- A. advise the client to decrease intake of fatty foods.
- B. schedule the client for a follow-up clinic visit in one month.
- C. inform the client that the cholesterol level is within normal limits.
- D. report the finding to the physician immediately.
Correct Answer: A
Rationale: A cholesterol level of 200 mg/dL is borderline high; reducing fatty foods is appropriate. Options B, C, and D are less immediate or incorrect.
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A 20-year-old woman with a fracture of the left femur is placed in Buck's traction with a 7-lb weight. The patient keeps sliding down in bed.
The nurse should
- A. elevate the patient's left thigh on two pillows.
- B. elevate the foot of the bed on blocks.
- C. raise the knee gatch on the bed 30°.
- D. instruct the patient to remain in the middle of the bed.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will not prevent patient from sliding down; may change pull of traction (2) correct-will keep leg straight and counter the pull of the weights (3) will bend the leg and alter the pull of the traction (4) not effective way of preventing the patient from sliding down in bed
An older man is being prepared for discharge after treatment for dehydration.
Which of the following statements, if made by the patient to the nurse, indicates that further teaching is needed?
- A. I should weigh myself daily.'
- B. I should drink fluids throughout the day.'
- C. I can use a measuring cup to find out how much I drink during the day.'
- D. I should let my doctor know if I get dizzy when I change positions.'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to dehydration. Be careful, this is a negative question. (1) correct-would only indicate overhydration, not response to dehydration (2) will help prevent recurrence of dehydration, should force fluids to 3,000 cc/day (3) would give good indication of total intake (4) would indicate postural hypotension resulting from volume deficit
The nurse is caring for an adult who had a cervical laminectomy this morning. After an uneventful stay in the postanesthesia care unit, the client is returned to the nursing care unit. How should the client be positioned immediately upon return?
- A. Supine
- B. Prone
- C. Semi-reclining
- D. Side-lying
Correct Answer: C
Rationale: Semi-reclining reduces neck strain and swelling post-cervical laminectomy, promoting comfort and healing. Supine or prone may increase pressure, and side-lying is less optimal.
Which of the following should be included in the discharge teaching of a client with a unilateral adrenalectomy?
- A. The client's need to pay close attention to skin care
- B. The client's need to restrict dietary intake of sodium and protein
- C. The client's need to recognize signs of hypoglycemia
- D. The client's need for daily steroid medication
Correct Answer: D
Rationale: Unilateral adrenalectomy may impair cortisol production, requiring lifelong steroid replacement. Skin care, dietary restrictions, and hypoglycemia are not primary concerns.
The nurse evaluates the nutritional intake of a 16-year-old girl at a camp for adolescents. The girl eats all of the food provided to her at the camp cafeteria. Each of the day's three meals contains foods from all areas of the food pyramid, and each meal averages about 900 calories and 3 mg of iron. The girl has been menstruating monthly for about two years. Which of the following descriptions, if made by the nurse, BEST describes the girl's intake if her weight is appropriate for her height?
- A. Her diet is low in calories and high in iron.
- B. Her diet is low in calories and low in iron.
- C. Her diet is high in calories and low in iron.
- D. Her diet is high in calories and high in iron.
Correct Answer: C
Rationale: 900 × 3 = 2,700 calories/day and women need 1,200-1,500 kcal/day (men need 1,500-1,800 kcal/day); 3 mg × 3 = 9 mg/day of iron and women need 15 mg/day of iron (men need 10 mg/day); with pregnancy 30 mg/day required