Management of the foregoing patient should include:
- A. Regular diet with extra fruits and green vegetables
- B. Potassium-sparing diuretics
- C. Discontinuance of any oral magnesium salts
- D. All of the above measures
Correct Answer: D
Rationale: The correct answer is D because a regular diet with extra fruits and green vegetables can provide essential nutrients for overall health, potassium-sparing diuretics can help manage potassium levels in the body, and discontinuing oral magnesium salts can prevent further complications in the patient. Option A focuses on promoting a healthy diet, B addresses specific medication for potassium management, and C avoids potential interactions with magnesium salts. Therefore, all of the measures (A, B, and C) are necessary for comprehensive management of the patient's condition.
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Which of the ff should the nurse identify as the earliest symptom of heart failure in many older clients?
- A. Increased urine output
- B. Dyspnea on exertion
- C. Swollen joints
- D. Nausea and vomiting
Correct Answer: B
Rationale: The correct answer is B: Dyspnea on exertion. In older clients, dyspnea on exertion is often the earliest symptom of heart failure due to decreased cardiac reserve. This occurs when the heart cannot pump enough blood to meet the body's demands during physical activity. Increased urine output (A) is not typically an early symptom of heart failure. Swollen joints (C) are more indicative of arthritis or inflammation, not necessarily heart failure. Nausea and vomiting (D) are not typical early symptoms of heart failure and are more commonly associated with gastrointestinal issues.
A client receiving chemotherapy has a nursing diagnosis of Deficient diversional activity related to decreased energy. Which statement indicates an accurate understanding of appropriate ways to deal with this deficit?
- A. “I’ll play card games with my friends.”
- B. “I’ll bowl with my team after discharge.”
- C. “I’ll take a long trip to visit my aunt.”
- D. “I’ll eat lunch in a restaurant everyday.”
Correct Answer: A
Rationale: The correct answer is A because playing card games with friends is a low-energy activity suitable for someone with decreased energy due to chemotherapy. This option promotes social interaction and mental stimulation, addressing the deficient diversional activity.
B, bowling with a team, involves physical activity and may be too strenuous for someone with decreased energy. C, taking a long trip, requires significant energy and may not be feasible. D, eating lunch in a restaurant, does not address the need for diversional activity and is not specific to the client's energy limitations.
Nurse Nancy also gives a lecture at the community health center about the diet for patients with ulcerative colitis. Which one is appropriate?
- A. high calorie, low protein
- B. low fat, high fiber
- C. high protein, low residue
- D. low sodium, high carbohydrate
Correct Answer: C
Rationale: The correct answer is C: high protein, low residue. For patients with ulcerative colitis, a high protein diet helps in tissue healing and repair. Low residue foods are recommended to reduce bowel irritation. Choice A is incorrect because low protein can impair healing. Choice B is unsuitable as high fiber may worsen symptoms. Choice D is not ideal as high carbohydrate can be difficult to digest for colitis patients.
Which of the following types of care plans is most likely to enable the nurse to take a holistic view of the client’s situation?
- A. Kardex
- B. Case management
- C. Critical pathways
- D. Concept map care plan
Correct Answer: D
Rationale: The correct answer is D: Concept map care plan. This type of care plan allows the nurse to visually represent the client's entire situation, including physical, emotional, and social aspects. By using interconnected concepts and relationships, the nurse can see the whole picture and identify potential interventions. Kardex (A) is a concise patient information summary, not comprehensive. Case management (B) focuses on coordinating services but may not capture the holistic view. Critical pathways (C) outline specific steps in care but may not address the client as a whole.
When can a donor and recipient of blood be considered compatible?
- A. If there is no change in the blood color when both samples are mixed in the laboratory
- B. If there are blood clots when both samples are mixed in the laboratory
- C. If there is no clumping or hemolysis when both samples are mixed in the laboratory
- D. If a blood drop does not sink when dropped in water after both samples are mixed in the laboratory
Correct Answer: C
Rationale: The correct answer is C because compatibility between blood donor and recipient is determined by the absence of clumping or hemolysis when both samples are mixed. Clumping indicates an incompatible blood type reaction, leading to potential harm. Blood clots (option B) are not indicative of compatibility but rather a sign of coagulation issues. Blood color change (option A) and blood drop sinking in water (option D) are not reliable indicators of blood compatibility. In summary, option C is correct as it directly assesses for the absence of a harmful reaction, while the other choices do not accurately determine blood compatibility.