During the rehabilitative phase following his cerebrovascular accident, Mr. K. is taught measures to relieve or prevent constipation. Which of these statements indicates that Mr. K. needs further health teaching?
- A. I eat whole-wheat bread with my meals.'
- B. I eat fruit three times a day.'
- C. I don't drink fluids after 4 P.M.'
- D. I don't like to take enemas.'
Correct Answer: C
Rationale: Restricting fluid intake after 4 P.M. can contribute to dehydration and constipation, making this statement indicative of the need for further education on proper hydration practices.
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For the nursing diagnoses and written patient outcomes listed below, use the Nursing Interventions Classification (NIC) to identify a specific nursing intervention to help the patient reach the outcome.
- A. Risk for impaired skin integrity related to immobility
- B. Constipation related to inadequate fluid and fiber intake
- C. None
- D. All
Correct Answer: A
Rationale: For preventing pressure ulcers, interventions like turning and positioning are critical. For constipation, increasing fluid and fiber intake is key.
Cognitive changes include memory problems, confusion, and disorientation. These changes:
- A. Occur in 75% of patients over age 65
- B. Are not a normal part of aging
- C. Are due to enhanced cerebral blood flow
- D. Cause senile plaques and neurofibrillary tangles
Correct Answer: B
Rationale: Cognitive decline is not a normal part of aging; it may indicate underlying conditions such as dementia or Alzheimer's disease. Normal aging involves mild forgetfulness but not significant impairment.
Describe the differences in action of SSRIs, SNRIs, and atypical antidepressants.
- A. High blood pressure
- B. Increased heart rate
- C. Decreased oxygen supply
- D. Muscle relaxation
Correct Answer: D
Rationale: The correct answer is D because it is the most appropriate response based on physiological and medical principles.
What information should be immediately reported to the physician?
- A. The ingested children's chewable vitamins contain iron
- B. The child has been treated several times for ingestion of toxic substances
- C. The child has been treated several times for accidental injuries
- D. The child was nauseated and vomited once at home
Correct Answer: A
Rationale: Iron ingestion can cause severe toxicity and requires immediate medical attention.
Which statement by a patient with diabetes indicates an understanding of the medication insulin glargine injection (Lantus)?
- A. Lantus causes weight loss.
- B. Lantus is used only at night.
- C. The duration of Lantus is six hours.
- D. There is no peak time for Lantus.
Correct Answer: D
Rationale: Lantus is a long-acting insulin with no distinct peak action.
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