Nokea
The 22-year-old female who is obese is discussing weight loss programs with the nurse. Which information should the nurse teach?
- A. Jog for two (2) to three (3) hours every day.
- B. Lifestyle behaviors must be modified.
- C. Eat one (1) large meal every day in the evening.
- D. Eat 1,000 calories a day and don't take vitamins.
Correct Answer: B
Rationale: Modifying lifestyle behaviors (e.g., diet, exercise, habits) is essential for sustainable weight loss. Excessive jogging, one large meal, or extreme calorie restriction are unsafe.
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The nurse is caring for an elderly client diagnosed with acute gastritis. Which client problem is priority for this client?
- A. Fluid volume deficit.
- B. Altered nutrition: less than body requirements.
- C. Impaired tissue perfusion.
- D. Alteration in comfort.
Correct Answer: A
Rationale: Fluid volume deficit is the priority in elderly clients with acute gastritis due to vomiting/diarrhea, risking dehydration. Nutrition, perfusion, and comfort are secondary.
The 84-year-old client comes to the clinic complaining of right lower abdominal pain. Which question is most appropriate for the nurse to ask the client?
- A. When was your last bowel movement?
- B. Did you have a high-fat meal last night?
- C. Can you describe the type of pain?
- D. Have you been experiencing any gas?
Correct Answer: C
Rationale: Describing the type of pain (e.g., sharp, dull, colicky) helps differentiate causes like appendicitis, diverticulitis, or obstruction, guiding diagnosis. Bowel movements, diet, and gas are secondary.
The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication?
- A. Restrict sodium intake to 2 g/day.
- B. Limit oral fluids to 1,500 mL/day.
- C. Decrease the daily fat intake.
- D. Reduce protein intake to 60 to 80 g/day.
Correct Answer: D
Rationale: Reducing protein intake limits ammonia production, which exacerbates hepatic encephalopathy. Sodium, fluid, and fat restrictions are less directly related to this complication.
The client with a history of a duodenal ulcer is hospitalized with upper abdominal discomfort and projectile vomiting that has a foul odor. The nurse immediately notifies the HCP, concluding that the client may have developed which complication?
- A. Gastric perforation
- B. Gastrointestinal hemorrhage
- C. Gastric outlet obstruction
- D. Helicobacter pylori infection
Correct Answer: C
Rationale: A. Symptoms of perforation include severe abdominal pain; vomiting usually does not occur. B. The client with GI hemorrhage would have bright red or coffee-ground-colored emesis. C. Symptoms of gastric outlet obstruction include abdominal pain and projectile vomiting when the stomach fills enough to stimulate afferent nerve fibers relaying information to the vomiting center in the brain. The emesis may have a foul odor or contain food particles if the contents have been dormant in the stomach for a prolonged time period. D. Infection with H. pylori is not a complication of PUD; rather, it is a major cause of peptic ulcers.
The nurse is caring for the immediate postoperative client who had a laparoscopic cholecystectomy. Which task could the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Check the abdominal dressings for bleeding.
- B. Increase the IV fluid if the blood pressure is low.
- C. Ambulate the client to the bathroom.
- D. Auscultate the breath sounds in all lobes.
Correct Answer: C
Rationale: Ambulating the client is within the UAP’s scope, promoting recovery. Checking dressings, adjusting IV fluids, and auscultating breath sounds require RN assessment skills.