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In doing a nutritional assessment for Mrs. Collins who wants to lose weight, what should the nurse initially do?
- A. Ask her to describe her actual food intake and behaviors influencing eating
- B. Determine who does the cooking and shopping
- C. Determine what she knows about the basic four food groups
- D. Determine biochemical data such as urinalysis and blood chemistries
Correct Answer: A
Rationale: Understanding the patient's current eating habits and behaviors is crucial for tailoring an effective weight loss plan.
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Which manipulative and body-based technique uses pressure applied to the feet and hands?
- A. Massage
- B. Reflexology
- C. Shiatsu
- D. Chiropractic technique
Correct Answer: B
Rationale: Reflexology applies pressure to specific points on the feet and hands, stimulating corresponding body areas.
Total parenteral nutrition(TPN), is one of the home therapies being used for Chelsea Mann, 35, with acute ulcerative colitis causing massive diarrhea. She and her family will need instruction about:
- A. caring for the central catheter.
- B. how to mix the TPN solution.
- C. fixing malfunctions occuring in the IV pump.
- D. teaching the neighbors how to care for her.
Correct Answer: A
Rationale: Prevention of infection, and potential septicemia, is of prime importance for someone with a central catheter. Mixing TPN is a very specialized procedure, and should be done under laminar airflow by a pharmacist. IV pumps are machines that do malfunction, but the safest thing to do would be to get the manufacturer to do the repair. Having neighbors be a support to Chelsea and her family may not be possible. More information would be necessary prior to choosing this as an option for a nursing diagnosis.
A client with a history of gastrointestinal bleeding is taking warfarin (Coumadin). Which instruction should the nurse include in the teaching plan?
- A. Avoid eating foods high in vitamin K.
- B. Take aspirin for pain relief.
- C. Report any signs of bruising or bleeding to your healthcare provider.
- D. Limit fluid intake to 2 liters per day.
Correct Answer: C
Rationale: The correct answer is C: Report any signs of bruising or bleeding to your healthcare provider. This instruction is crucial because warfarin can increase the risk of bleeding, especially in clients with a history of gastrointestinal bleeding. Reporting any signs of bruising or bleeding promptly allows for timely intervention to prevent serious complications.
A: Avoiding foods high in vitamin K is not necessary, as consistent intake of vitamin K-containing foods can help maintain stable anticoagulant levels.
B: Taking aspirin along with warfarin can increase the risk of bleeding and should be avoided.
D: Limiting fluid intake is not directly related to the management of warfarin therapy or gastrointestinal bleeding.
The most common, preventable complication of abdominal surgery is
- A. atelectasis.
- B. fluid and electrolyte imbalance.
- C. thrombophlebitis.
- D. urinary retention.
Correct Answer: D
Rationale: Urinary retention is a common issue post-abdominal surgery due to anesthesia effects and immobility.
Joan asks you why she is being administered so many arterial blood gas tests. You respond by saying
- A. This test determines if your liver and kidneys are functioning properly.
- B. This test determines if you have sufficient WBC to fight infection.
- C. This test determines if you are hyperglycemic, which is a side effect of your medication.
- D. This test determines how well your tissues are oxygenated.
Correct Answer: D
Rationale: Arterial blood gas tests measure oxygenation and acid-base balance in the blood.