Nokea
Because of Mrs. West’s age, what should be given particular attention during assessment?
- A. Fluid and electrolyte balance
- B. Mental and emotional health status
- C. Respiratory function
- D. Drug allergies
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?
- A. Altered nutrition: less than body requirements.
- B. Potential complication hemorrhage.
- C. Ineffective individual coping.
- D. Fluid volume excess.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
How will recognizing that clients have different perceptions of time assist the nurse to provide more sensitive care?
- A. Adapting care plans to accommodate varying time perspectives.
- B. Enforcing strict schedules regardless of cultural differences.
- C. Ignoring time-related preferences.
- D. None of the above.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. Which finding should the nurse expect?
- A. Increased anterior-posterior (AP) chest diameter
- B. Decreased respiratory rate
- C. Weight gain
- D. Productive cough with yellow sputum
Correct Answer: A
Rationale: The correct answer is A: Increased anterior-posterior (AP) chest diameter. In COPD, the lungs lose their elasticity, trapping air and causing hyperinflation. This leads to increased AP chest diameter due to barrel chest appearance. Option B is incorrect because COPD often results in an increased respiratory rate due to difficulty breathing. Option C is incorrect as weight gain is not a typical finding in COPD, which is often associated with weight loss. Option D is incorrect as a productive cough with yellow sputum is more commonly seen in respiratory infections rather than COPD exacerbations.
The client has received preoperative teaching for a vertical partial laryngectomy. The nurse determines that the teaching has been effective when the client states:
- A. I know I will need special swallowing training after my surgery.'
- B. The quality of my voice will be excellent after surgery.'
- C. I will have very little difficulty swallowing after surgery.'
- D. I may also have to have a radical neck dissection done.'
Correct Answer: C
Rationale: Special swallowing training is required for a client with a supraglottic (horizontal partial) laryngectomy, not a vertical partial laryngectomy. The quality of the client's voice will be altered, but it will be adequate for communication. The client will have minimal difficulty swallowing. A radical neck dissection may be done with a total laryngectomy, not with a partial laryngectomy.
A nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet?
- A. A 4-ounce steak, French fries, iceberg lettuce
- B. Baked chicken breast, broccoli, tomatoes
- C. Fried catfish, cornbread, peas
- D. Spaghetti with meat sauce, garlic bread
Correct Answer: B
Rationale: The correct answer is B because it includes a lean protein (baked chicken breast) and high-fiber vegetables (broccoli, tomatoes) which are beneficial for managing elevated lipid levels. Lean protein helps reduce saturated fat intake while fiber from vegetables aids in lowering cholesterol levels. Choice A includes a high-saturated fat steak and French fries, not ideal for managing lipid levels. Choice C contains fried catfish and cornbread which are high in unhealthy fats and refined carbohydrates. Choice D has spaghetti with meat sauce and garlic bread, which are high in refined carbohydrates and saturated fats, not recommended for someone with elevated lipid levels.