Nokea
The client is preparing for a myelogram. Which of the following statements by the client indicates a contraindication for this test?
- A. I can't lie in one position for more than thirty minutes.
- B. I am allergic to shrimp.
- C. I suffer from claustrophobia.
- D. I developed a severe headache after a spinal tap.
Correct Answer: B
Rationale: An allergy to shrimp is a contraindication for a myelogram because the contrast dye used in the procedure contains iodine, which can trigger allergic reactions in individuals allergic to shellfish. Choices A, C, and D are not contraindications for a myelogram. Inability to lie still for an extended period, claustrophobia, or a previous headache after a spinal tap are concerns that can be managed during the procedure but do not necessarily prevent the test from being performed.
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A client is receiving treatment for hypertension. Which of these findings would be most concerning to the nurse?
- A. A heart rate of 90 beats per minute
- B. A blood pressure of 120/80 mm Hg
- C. A respiratory rate of 16 breaths per minute
- D. A temperature of 98.6 degrees Fahrenheit
Correct Answer: C
Rationale: The correct answer is C. A respiratory rate of 16 breaths per minute is within normal limits; however, changes in breathing patterns can indicate respiratory distress, which is concerning, especially in a client receiving treatment for hypertension. A heart rate of 90 beats per minute may not be alarming if the client is at rest. A blood pressure of 120/80 mm Hg is within the normal range for a healthy adult. A temperature of 98.6 degrees Fahrenheit is also considered normal, showing no immediate cause for concern in this scenario.
A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first?
- A. Institute seizure precautions
- B. Monitor neurologic status every hour
- C. Place in respiratory/secretion precautions
- D. Cefotaxime IV 50 mg/kg/day divided q6h
Correct Answer: C
Rationale: The correct answer is to place the child in respiratory/secretion precautions first. Meningococcal meningitis is highly contagious, and respiratory precautions are essential to prevent the spread of the infection. Seizure precautions may be necessary but are not the priority upon admission. Monitoring neurologic status is important but not the initial action needed. While antibiotic therapy like Cefotaxime is crucial, implementing isolation precautions to prevent transmission takes precedence in this situation.
A client has been diagnosed with hyperthyroidism. Which of these nursing diagnoses should receive the highest priority?
- A. Risk for injury related to exophthalmos
- B. Impaired social interaction related to emotional lability
- C. Imbalanced nutrition: Less than body requirements related to hypermetabolism
- D. Activity intolerance related to fatigue
Correct Answer: D
Rationale: The correct answer is 'D: Activity intolerance related to fatigue.' This nursing diagnosis should receive the highest priority for a client with hyperthyroidism. Hyperthyroidism often leads to symptoms such as fatigue, weakness, and muscle discomfort, which can significantly impact the client's ability to perform daily activities. Addressing activity intolerance is crucial to prevent exacerbation of symptoms and promote the client's overall well-being. Choices A, B, and C are important nursing diagnoses as well, but in the context of hyperthyroidism, addressing activity intolerance takes precedence over the risk for injury related to exophthalmos, impaired social interaction related to emotional lability, and imbalanced nutrition due to hypermetabolism.
A healthcare professional is assisting with the development of an education program about nutritional risk among adolescents to a group of parents of adolescents. Which of the following information should the healthcare professional include in the teaching? (Select all that apply).
- A. Skipping more than three meals per week
- B. Eating fast food once a week
- C. Hearty appetite
- D. Drink whole milk to ensure adequate calcium intake.
Correct Answer: A
Rationale: Skipping more than three meals per week is an indicator of poor nutritional habits in adolescents. This can lead to inadequate nutrient intake and negatively impact growth and development. Choices B, C, and D are not directly associated with poor nutritional habits among adolescents. Eating fast food once a week may not necessarily indicate poor nutrition if the overall diet is balanced. Having a hearty appetite does not provide specific information about nutritional risk, as appetite can vary among individuals. While whole milk can be a source of calcium, it is not necessary to drink whole milk specifically to ensure adequate calcium intake, as there are other sources of calcium available.
The nurse is providing discharge teaching to a client with hypertension. Which of these statements made by the client indicates an understanding of the teaching?
- A. I will limit my intake of high-sodium foods.
- B. I will take my medications as prescribed by my healthcare provider.
- C. I will monitor my blood pressure regularly and keep a record to show my healthcare provider.
- D. I will limit my intake of high-fat foods.
Correct Answer: A
Rationale: The correct answer is A because limiting high-sodium foods is essential in managing hypertension and preventing complications. High sodium intake can lead to increased blood pressure levels. Choice B is important too, but solely relying on medications without lifestyle modifications may not be as effective in controlling hypertension. Choice C is also crucial for monitoring progress, but without dietary changes, blood pressure control may be challenging. Choice D, limiting high-fat foods, is beneficial for overall health but is not as directly related to managing hypertension as limiting high-sodium foods.