Nokea
The A, B, C, and Ds of a complete and comprehensive nutritional assessment includes:
- A. Assessment data, biochemical data, clinical data and dietary data
- B. Ancestral cultural data, biochemical data, clinical data and dietary data
- C. Anthropometric data, biological data, chemical data and dietary data
- D. Anthropometric data, biochemical data, clinical data and dietary data
Correct Answer: D
Rationale: A comprehensive nutritional assessment includes Anthropometric data (e.g., height, weight), Biochemical data (e.g., lab values), Clinical data (e.g., physical signs), and Dietary data (e.g., intake history).
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A client with a history of liver failure is admitted with hepatic encephalopathy. The nurse should monitor the client for which of the following?
- A. Asterixis.
- B. Hypotension.
- C. Polyuria.
- D. Bradycardia.
Correct Answer: A
Rationale: Asterixis (flapping tremor) is a hallmark sign of hepatic encephalopathy due to ammonia buildup.
A client with alcohol dependence states, 'I feel so bad because of what I've done to my wife and kids. I'm just no good.' Which of the following responses by the nurse is most appropriate?
- A. You'll need to make up for a lot of things
- B. They will need to forgive your shortcomings
- C. Alcohol dependence is a disease that can be treated
- D. Alcoholism is painful for everyone involved
Correct Answer: C
Rationale: Framing alcohol dependence as a treatable disease offers hope and reduces self-blame, supporting recovery. Other responses may reinforce guilt or are less therapeutic.
For which of the following should the nurse be especially alert when caring for a term neonate, who weighed 10 lb at birth, 1 hour after a vaginal delivery?
- A. Hypoglycemia.
- B. Hypercalcemia.
- C. Hypermagnesemia.
- D. Hyperbilirubinemia.
Correct Answer: A
Rationale: The neonate would be considered large for gestational age (LGA) because the neonate weighs more than 4,000 g (90th percentile). Hypoglycemia is a problem for the LGA neonate because glycogen stores are quickly used to maintain the weight. Other complications like hyperbilirubinemia may occur, but hypoglycemia is the priority concern within the first hour.
You are the Assistant Director of Nursing in a multi ethnic and culturally diverse inner city acute care facility. You will be chairing a committee to develop a philosophy of nursing that addresses these facility characteristics and the characteristics of the clients. Which theoretical framework would you recommend that this committee should consider when addressing multi ethnicity and the culturally diverse nature of this facility for this philosophy?
- A. Jean Watson's
- B. Martha Rogers'
- C. Nagi's theory
- D. Madeleine Leininger's theory
Correct Answer: D
Rationale: Madeleine Leininger's theory of Transcultural Nursing focuses on providing culturally congruent care, making it the most appropriate framework for addressing the needs of a multi-ethnic and culturally diverse population.
Which of the following medications should the nurse anticipate administering in the event of a heparin overdose?
- A. Warfarin sodium (Coumadin).
- B. Protamine sulfate.
- C. Acetylsalicylic acid (ASA).
- D. Atropine sulfate.
Correct Answer: B
Rationale: Protamine sulfate is the antidote for heparin overdose, neutralizing its anticoagulant effects.