Nokea
Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include:
- A. A ham and Swiss cheese sandwich on whole wheat bread
- B. Mashed potatoes and broiled chicken
- C. A tossed salad with oil and vinegar and olives
- D. Chicken bouillon
Correct Answer: B
Rationale: Mashed potatoes and broiled chicken are low in sodium, unlike ham, olives, or bouillon.
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The nurse is preparing a client with gout for discharge. Which dietary selection reflects an understanding of the client's condition?
- A. Broiled chicken, rice, and iced tea
- B. Sardines, lima beans, and red wine
- C. Hamburger, fries, and a milkshake
- D. Shrimp, spinach, and beer
Correct Answer: A
Rationale: Broiled chicken, rice, and iced tea suit gout, avoiding purine-rich foods (sardines, shrimp) or alcohol (wine, beer) that raise uric acid lima beans and spinach also contribute less but aren't ideal. Nurses teach this, reducing flare-ups, supporting joint health and client compliance.
Your assigned client seems to be getting a lot of attention from his mother when he complains of pain. The mother may be encouraging which of the following types of gains?
- A. primary gains
- B. secondary gains
- C. narcissistic gains
- D. egocentric gains
Correct Answer: B
Rationale: Maternal attention for pain suggests secondary gains external benefits beyond primary relief or other gains. Nurses address this in behavioral pain management.
The nurse questions a doctors order of Morphine sulfate 50 mg, IM for a client with pancreatitis. Which role best fit that statement?
- A. Change agent
- B. Client advocate
- C. Case manager
- D. Collaborator
Correct Answer: B
Rationale: Questioning an inappropriate order like morphine for pancreatitis, which worsens sphincter of Oddi spasm reflects the client advocate role. Nurses protect patient rights and safety by challenging harmful directives, ensuring optimal care (e.g., suggesting alternatives like meperidine). This differs from change agent (lifestyle shifts), case manager (coordination), or collaborator (teamwork), emphasizing advocacy's focus on patient well-being, a core ethical duty in nursing.
The physician has ordered a culture specimen from a client with a suspected urinary tract infection. The nurse is aware that the specimen should be obtained:
- A. From the first morning voiding
- B. Using a sterile cotton ball placed in the client's vaginal area
- C. From the client's indwelling catheter port
- D. During the client's midstream voiding
Correct Answer: D
Rationale: Midstream voiding provides a clean-catch urine specimen for UTI culture, minimizing contamination first voiding risks sediment, vaginal cotton is irrelevant, and catheter ports are for indwelling cases. Nurses instruct this technique, ensuring accurate pathogen identification, critical for effective treatment.
The nurse raised her fist to Mr. Gary who refused his medication. This is an example of?
- A. Malpractice
- B. Negligence
- C. Assault
- D. Battery
Correct Answer: C
Rationale: Raising a fist to Mr. Gary is assault (C) intentional threat, per law. Malpractice (A) and negligence (B) are care failures, battery (D) requires touch. C fits the threatening act, making it correct.