Nokea
In response to a question about use of alcohol, a patient asks the nurse why the nurse needs that information. What reason would the nurse give the patient?
- A. This is necessary to determine the patient's reliability.
- B. Alcohol can interact with medications and can make some diseases worse.
- C. The nurse is required to teach the patient about the dangers of alcohol use.
- D. It is not really necessary to ask for this information unless there is an obvious drinking problem.
Correct Answer: B
Rationale: The correct answer is B because alcohol can interact with medications and exacerbate certain medical conditions. The nurse needs this information to ensure the patient's safety and well-being. Choice A is incorrect because the question is not about the patient's reliability. Choice C is incorrect as it assumes the nurse is required to educate the patient about alcohol dangers. Choice D is incorrect because even without an obvious drinking problem, alcohol use can still impact the patient's health.
You may also like to solve these questions
What should be done for a client who is post-op and develops a fever within the first 48 hours?
- A. Administer antipyretics
- B. Monitor for signs of infection
- C. Administer fluids
- D. Perform an abdominal assessment
Correct Answer: B
Rationale: The correct answer is B: Monitor for signs of infection. Within the first 48 hours post-op, fever is often indicative of an infection. Monitoring for signs such as increased pain, redness, swelling, warmth at the surgical site, elevated white blood cell count, and changes in vital signs helps in early detection and prompt treatment of infections. Administering antipyretics (choice A) may help reduce fever but does not address the underlying cause. Administering fluids (choice C) is important for hydration but does not directly address the fever's cause. Performing an abdominal assessment (choice D) is not specific to addressing fever in a post-op client.
Which technique should the nurse use to determine the presence of crepitus during a physical examination?
- A. Percussion
- B. Auscultation
- C. Palpation
- D. Auscultation
Correct Answer: A
Rationale: The correct technique to determine the presence of crepitus during a physical examination is palpation. Crepitus is a crackling or grating sensation that is felt when there is air trapped in the subcutaneous tissue. Palpation involves using the hands to feel for abnormalities such as crepitus. Percussion involves tapping on the body to produce sounds that can help assess underlying structures, not to determine the presence of crepitus. Auscultation is listening to sounds within the body using a stethoscope, which is not relevant for detecting crepitus.
Which condition is associated with inadequate intake of vitamin C?
- A. Rickets
- B. Marasmus
- C. Kwashiorkor
- D. Scurvy
Correct Answer: D
Rationale: The correct answer is D: Scurvy. Scurvy is caused by a deficiency in vitamin C, which is essential for collagen synthesis. Without enough vitamin C, collagen production is impaired, leading to symptoms like bleeding gums, fatigue, and joint pain.
Incorrect Choices:
A: Rickets is caused by a deficiency in vitamin D, not vitamin C.
B: Marasmus is a severe form of malnutrition due to inadequate intake of calories and protein, not specifically vitamin C.
C: Kwashiorkor is a form of severe acute malnutrition typically caused by inadequate protein intake, not vitamin C deficiency.
In summary, the correct answer is D (Scurvy) because it directly relates to inadequate intake of vitamin C, while the other choices are associated with different nutrient deficiencies.
A patient tells the nurse that he is very nervous, that he is nauseated, and that he "feels hot." This type of data would be:
- A. objective.
- B. reflective.
- C. subjective.
- D. introspective.
Correct Answer: C
Rationale: The correct answer is C: subjective. Subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient's report of feeling nervous, nauseated, and hot is subjective because it reflects their personal sensations and cannot be measured or observed directly by the nurse. Objective data (choice A) is measurable and observable, such as vital signs or physical examination findings. Reflective (choice B) and introspective (choice D) do not accurately describe the type of data provided by the patient in this scenario. The patient's symptoms are subjective because they are based on the patient's own feelings and experiences, making choice C the most appropriate answer.
Which client should avoid foods high in potassium?
- A. a client receiving diuretic therapy
- B. a client with an ileostomy
- C. a client with metabolic alkalosis
- D. a client with renal disease
Correct Answer: D
Rationale: The correct answer is D because clients with renal disease may have impaired kidney function, leading to difficulty in regulating potassium levels. High potassium intake can further burden the kidneys, potentially causing hyperkalemia. Clients on diuretic therapy (choice A) may actually need to monitor potassium levels due to potential electrolyte imbalances. Clients with an ileostomy (choice B) typically do not have issues with potassium absorption. Clients with metabolic alkalosis (choice C) may have potassium shifts but do not necessarily need to avoid high-potassium foods unless specifically advised by their healthcare provider.