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For breakfast on the morning a client is to have an electroencephalogram (EEG), the client is served a soft-boiled egg, toast with butter and marmalade, orange juice, and coffee. Which of the following should the nurse do?
- A. Remove all the food.
- B. Remove the coffee.
- C. Remove the toast, butter, and marmalade only.
- D. Substitute vegetable juice for the orange juice.
Correct Answer: B
Rationale: Coffee should be removed because caffeine can alter brain wave activity, affecting EEG results. The other foods do not typically interfere with the test.
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A 32-year-old female meets with the nurse on her first office visit since undergoing a left mastectomy. When asked how she is doing, the woman says her appetite is still not good, she is not getting much sleep because she doesn't go to bed until her husband is asleep, and she is really anxious to get back to work. Which of the following nursing interventions should the nurse explore to support the client's current needs?
- A. Call the physician to discuss allowing the client to return to work earlier.
- B. Suggest that the client learn relaxation techniques for help with her insomnia.
- C. Perform a nutritional assessment to assess for anorexia.
- D. Ask open-ended questions about sexuality issues related to her mastectomy.
Correct Answer: B
Rationale: Insomnia is a primary concern, and relaxation techniques can help improve sleep, addressing the client's emotional and physical recovery needs post-mastectomy.
As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by:
- A. Antispasmodic effects on the pericardium.
- B. Causing an increased myocardial oxygen demand.
- C. Vasodilation of peripheral vasculature.
- D. Improved conductivity in the myocardium.
Correct Answer: C
Rationale: Nitroglycerin causes vasodilation of peripheral and coronary vasculature, reducing preload and myocardial oxygen demand, relieving angina.
What should the nurse teach a client about stoma care?
- A. Clean with hydrogen peroxide.
- B. Measure stoma size weekly.
- C. Apply adhesive remover.
- D. Change pouch every day.
Correct Answer: B
Rationale: Measuring stoma size weekly ensures proper appliance fit as swelling subsides.
An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first?
- A. A woman who is 5 months pregnant with no apparent injuries.
- B. A middle-aged man with no injuries who has rapid respirations and coughs.
- C. A 10-year-old with a simple fracture of the humerus who is in severe pain.
- D. A 20-year-old with first-degree burns on her hands and forearms.
Correct Answer: B
Rationale: Rapid respirations and coughing suggest possible smoke inhalation, which can lead to airway compromise and requires urgent evaluation and transport.
A client is being admitted with a spinal cord transection at C7. Which of the following assessments take priority upon the client's arrival?
- A. Reflexes.
- B. Bladder function.
- C. Blood pressure.
- D. Temperature.
- E. Respirations.
Correct Answer: C,E
Rationale: Respirations and blood pressure are the priority assessments for a C7 spinal cord injury, as this level can impair diaphragmatic function and cause neurogenic shock, both life-threatening. Reflexes, bladder function, and temperature are important but secondary to airway and circulation stability.