Nokea
Kenneth, 25 year old diagnosed with HIV felt that he had not lived up with God's expectation. He fears that in the course of his illness, God will be punitive and not be supportive. What kind of spiritual crisis is Kenneth experiencing? 1. Spiritual Pain 2. Spiritual Anxiety 3. Spiritual Guilt 4. Spiritual Despair
- A. 1,2
- B. 2,3
- C. 3,4
- D. 1,4
Correct Answer: B
Rationale: Kenneth faces spiritual anxiety (2) and guilt (3). Anxiety stems from fear of divine punishment, and guilt from feeling he failed God's expectations, per spiritual distress frameworks. Spiritual pain (1) involves loss or meaning, not fear-based here. Despair (4) is hopelessness, not evident as he fears, not resigns. HIV's stigma amplifies 2 and 3, making B (2,3) correct.
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Which intervention should the nurse implement to maintain adequate hydration in an immobile patient?
- A. Offering fluids at room temperature
- B. Limiting fluid intake to prevent incontinence
- C. Providing a straw for easier drinking
- D. Administering intravenous fluids continuously
Correct Answer: A
Rationale: Offering room-temperature fluids maintains hydration in immobile patients by encouraging intake comfortably, supporting circulation and organ function. Limiting fluids risks dehydration, straws help but aren't universal, and IV fluids aren't routine. Nurses promote this to ensure fluid balance, adapting to patient preferences, a simple yet effective hydration strategy in restricted mobility cases.
A client has a new diagnosis of nephrotic syndrome, and the nurse is providing dietary management education. Which of the following statements should the nurse include in the teaching?
- A. You should increase your intake of high-sodium foods.
- B. You should decrease your intake of high-sodium foods.
- C. You should avoid foods that contain lactose.
- D. You should increase your intake of dairy products.
Correct Answer: B
Rationale: For a client with nephrotic syndrome, decreasing the intake of high-sodium foods is essential to manage fluid retention and symptoms of the condition. Excessive sodium can lead to fluid retention, swelling, and worsen the condition. Therefore, advising the client to decrease their high-sodium food intake aligns with the dietary management approach to help control nephrotic syndrome. Choices A, C, and D are incorrect. Increasing high-sodium foods would exacerbate fluid retention, avoiding lactose is not specifically required for nephrotic syndrome, and increasing dairy products may not be necessary unless individualized based on the client's needs and lab values.
The nurse is planning care for a client with a chronic illness. Which intervention reflects tertiary prevention?
- A. Screening the client for depression
- B. Teaching the client strategies for living with the illness
- C. Encouraging the client to receive an annual flu vaccine
- D. Educating the client about preventing transmission of illness
Correct Answer: B
Rationale: Tertiary prevention optimizes life with a chronic illness, reducing its impact post-diagnosis. Teaching strategies for living with it like pacing activities for arthritis helps the client adapt, minimizing disability and enhancing function, a nursing priority. Screening for depression is secondary, detecting new issues, not managing the existing one. An annual flu vaccine is primary, preventing unrelated illness, not addressing the chronic condition's effects. Educating about transmission fits infectious cases, not all chronic ones. This intervention tailored coping reflects nursing's role in rehabilitation, ensuring clients thrive despite limits. For instance, teaching a heart failure client fluid management cuts readmissions, aligning with tertiary care's focus on sustaining quality of life through practical, illness-specific support.
The nurse is performing a physical assessment on a client with a history of gout. The nurse should assess the client for:
- A. Pain and swelling of the affected joint
- B. Increased urinary output
- C. Fever with a temperature greater than 101°F
- D. Numbness in the affected extremity
Correct Answer: A
Rationale: Pain and swelling of the affected joint (often the big toe) are classic gout signs due to uric acid crystal deposits increased urine, fever, or numbness aren't typical. Nurses assess for redness and warmth, guiding anti-inflammatory treatment, critical for managing this metabolic disorder's acute flares.
When teaching a client with a new diagnosis of hypertension about medication adherence, which statement should the nurse include?
- A. You can stop taking your medication once your blood pressure is normal.
- B. You should take your medication at the same time every day.
- C. You can double your dose if you miss a dose.
- D. You should take your medication with a high-fat meal.
Correct Answer: B
Rationale: The correct answer is B: 'You should take your medication at the same time every day.' Taking medication consistently at the same time daily is crucial for maintaining steady blood levels and effectively managing hypertension. It helps ensure that the medication works optimally and provides the best control of blood pressure throughout the day. Choice A is incorrect because stopping medication once blood pressure is normal can lead to a relapse or worsening of hypertension. Choice C is incorrect as doubling the dose without healthcare provider guidance can be dangerous. Choice D is incorrect as taking medication with a high-fat meal can affect its absorption and efficacy.