Nokea
Select the 3 statements the nurse should include in the teaching.
- A. Notify your provider if you experience vomiting or diarrhea.
- B. Limit alcohol intake to no more than one drink per day
- C. You should eat foods that are low in fat.
- D. You can drink beverages that contain caffeine.
- E. You should eat foods highs in protein.
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. A is important as vomiting and diarrhea can lead to dehydration. B is crucial for liver health and overall well-being. C is essential for heart health and maintaining a healthy weight. The other choices are incorrect. D can worsen symptoms and interfere with medication. E may not be suitable for certain health conditions and can lead to weight gain. No information is provided for options F and G.
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A nurse is admitting a client who has schizophrenia. The client state nurse to state?"I'm hearing voices. Which of the following responses is the priority for the nurse to state"
- A. What are the voices telling you?
- B. I realize the voices are real to you, but I don't hear anything.â€
- C. Have you taken your medication today?â€
- D. How long have you been hearing the voices?
Correct Answer: A
Rationale: The correct answer is A: "What are the voices telling you?" This response shows active listening and encourages the client to express their thoughts, helping the nurse assess the content and potential danger of the voices. Choice B dismisses the client's experience, choice C focuses on medication compliance rather than immediate safety, and choice D is relevant but does not address the immediate concern.
For each assessment finding, click to specify if the finding is an indication of physical maltreatment, neglect, or financial maltreatment.
- A. Client reports having little food in the house.
- B. Client has bruises in various stages of healing.
- C. Client wears dirty clothing
- D. Client has no access to bank accounts
Correct Answer: A,B,C,D
Rationale: These findings suggest multiple forms of maltreatment.
A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
- A. Instruct the client to lift her chin when swallowing
- B. Talk with the client during her feeding.
- C. Sit at or below the client's eye level during feedings
- D. Discourage the client from coughing during feedings
Correct Answer: C
Rationale: The correct answer is C: Sit at or below the client's eye level during feedings. This is important for clients with dysphagia as it helps facilitate safe swallowing by promoting proper alignment of the head and neck. Sitting at or below the client's eye level reduces the risk of aspiration and choking during feeding. This position also allows the nurse to closely monitor the client for signs of difficulty swallowing.
Choice A is incorrect because instructing the client to lift her chin when swallowing can actually increase the risk of aspiration in individuals with dysphagia. Choice B is incorrect as talking with the client during feeding may distract them and increase the risk of swallowing difficulties. Choice D is incorrect because coughing is a protective mechanism that helps clear the airway, so discouraging coughing during feedings is not recommended for clients with dysphagia.
The client is at risk for developing-----due to---
- A. mania
- B. serotonin syndrome
- C. psychosis
- D. feelings of hopelessness
- E. adverse effects of paroxetine
- F. anxiety
Correct Answer: B,E
Rationale: Increasing paroxetine while discontinuing fluoxetine can lead to serotonin syndrome.
Which of the following findings indicates the newborn is experiencing withdrawal?
- A. Bulging fontanels
- B. Acrocyanosis
- C. Bradycardia
- D. Hypertonicity
Correct Answer: D
Rationale: The correct answer is D: Hypertonicity. This finding indicates the newborn is experiencing withdrawal because it is a common symptom of withdrawal from substances such as opioids or benzodiazepines. Hypertonicity refers to increased muscle tone, which can be observed through increased resistance to passive movement. It is a sign of central nervous system hyperirritability, often seen in newborns going through withdrawal. Bulging fontanels (A) are a sign of increased intracranial pressure. Acrocyanosis (B) is a normal finding in newborns and is due to immature circulation. Bradycardia (C) is a slow heart rate, which can be caused by various factors in newborns, not specifically indicative of withdrawal.