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Jane, an obese hypertensive homemaker, complains of continual hunger and lack of energy. What nursing measure would be most helpful?
- A. Giving her a list of low-calorie foods
- B. Discussing the importance of eating breakfast
- C. Recommending a strict vegetarian diet
- D. Suggesting vitamin supplements
Correct Answer: B
Rationale: Eating breakfast helps regulate metabolism and energy levels throughout the day, reducing hunger and fatigue.
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What evaluation would help Mr. Jones control his chest pain on inspiration?
- A. Evaluate the intensity and quality of his pain
- B. Explain the cause of his pain
- C. Encourage him to lie on his affected side
- D. Reassure him that the pain will subside
Correct Answer: C
Rationale: Lying on the affected side stabilizes the chest wall, reducing pain during inspiration.
The nurse is reviewing the laboratory results for a preoperative patient. Which test result should be brought to the attention of the surgeon immediately?
- A. Serum K+ of 3.8 mEq/L
- B. Hemoglobin of 15 g/dL
- C. Blood glucose of 100 mg/dL
- D. White blood cell (WBC) count of 18,500/µL
Correct Answer: D
Rationale: An elevated WBC count indicates potential infection, requiring immediate attention.
How can a nurse foster effective coping skills?
- A. Deep breathing exercises
- B. Avoid social interactions
- C. Ignore stressors
- D. Increase workload
Correct Answer: B
Rationale: The correct answer is B because it is the most appropriate response based on physiological and medical principles.
A patient who completed detoxing from heroin tells you that his or her family members who are not substance abusers do not understand how it feels to go through withdrawal. He or she asks you for advice. Which of the following is the best response?
- A. Tell your family members to attend Alcoholics Anonymous.
- B. Ask your family members if they ever had the flu. Tell them that withdrawal is like having the worst flu they ever had.
- C. Tell your family member that going through withdrawal is like going on a diet.
- D. Tell your family member to try heroin once.
Correct Answer: B
Rationale: Comparing withdrawal to a severe flu helps family members understand the physical symptoms without trivializing the experience.
A client is scheduled for a pneumonectomy in the morning. The client has had a previous negative surgical experience, is talking rapidly, and has an increased pulse and respiratory rate. Nursing interventions for this client should include:
- A. providing opportunities for questions and talking about the client's concerns.
- B. providing distractions such as reading or watching television.
- C. assuring the client that everything will be all right.
- D. reminding the client that the surgery is not as extensive as the client's past surgery.
Correct Answer: A
Rationale: Providing an opportunity for an open discussion will help to clarify any misunderstandings about the surgery and gives the client a chance to verbalize any concerns about the surgery. Distractions will not alleviate the client's preoperative anxiety; it denies the anxiety the client is experiencing. Giving false assurance is not appropriate and it denies that anxiety is a normal response to the threat of surgery. Psychological responses are not directly related to the severity of the surgery; they are influenced by the client's experience.