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The client is unable to void, and the plan of care sets an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document to indicate a successful outcome?
- A. Drinks adequate fluids.
- B. Void without difficulty.
- C. Feels less thirsty.
- D. Drinks 240 mL of fluid five times during the shift.
Correct Answer: D
Rationale: The correct answer is D. Drinking 240 mL of fluid five times during the shift indicates a fluid intake of 1200 mL, which exceeds the minimum objective of at least 1000 mL. The client meeting or exceeding the fluid intake goal is a clear indicator of a successful outcome. Choices A, B, and C are incorrect because simply drinking adequate fluids, voiding without difficulty, or feeling less thirsty do not directly demonstrate meeting the specific objective of fluid intake set in the care plan.
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The school nurse is coaching a group of high school students on ways to deal with the stress of final exams. Today the class is focusing on healthy food choices for lunch in the school cafeteria. Which option should the nurse recommend?
- A. cheeseburger on a whole wheat bun, French fries, and a large cola beverage
- B. tuna casserole with peas and corn, a fresh apple, crackers, and orange juice
- C. fruit salad with fresh berries and oranges, chicken vegetable soup, and tea
- D. chef salad with turkey, ham, and ranch dressing, apple juice, and milk
Correct Answer: C
Rationale: The recommended option for managing stress during final exams is a balanced and nutritious meal. Fruit salad with fresh berries and oranges, chicken vegetable soup, and tea offer a variety of nutrients and antioxidants that can help combat stress. Option A is not ideal as it includes high-fat and high-calorie foods. Option B is a good choice, but Option C provides a wider range of nutrients and hydration. Option D is a healthy choice with a variety of proteins and vitamins, but Option C offers lighter options that may be easier to digest during stressful times.
A public health nurse is evaluating a program designed to reduce childhood obesity. Which outcome indicates that the program is successful?
- A. increased participation in physical activities
- B. higher attendance at nutrition education sessions
- C. reduced rates of childhood obesity
- D. greater knowledge of healthy eating habits
Correct Answer: C
Rationale: The correct answer is C: reduced rates of childhood obesity. A reduction in childhood obesity rates is a direct indicator that the program is successful in achieving its goal. Increased participation in physical activities (choice A) and higher attendance at nutrition education sessions (choice B) are positive outcomes, but they do not directly measure the program's effectiveness in reducing obesity. Greater knowledge of healthy eating habits (choice D) is important but does not guarantee a decrease in obesity rates. Therefore, the most significant outcome to determine the success of a childhood obesity reduction program is a reduction in obesity rates.
The healthcare provider is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which intervention is most important?
- A. Restrict fluids to 1,000 mL per day.
- B. Administer a vasopressin antagonist.
- C. Monitor intake and output.
- D. Encourage a high-sodium diet.
Correct Answer: B
Rationale: Administering a vasopressin antagonist is the most critical intervention for a client with SIADH. SIADH is characterized by excessive release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia. A vasopressin antagonist helps manage the symptoms by blocking the effects of ADH, promoting water excretion, and restoring electrolyte balance. Restricting fluids (choice A) may exacerbate hyponatremia, monitoring intake and output (choice C) is important but not the most critical intervention, and encouraging a high-sodium diet (choice D) is contraindicated in SIADH due to the risk of worsening hyponatremia.
The nurse is planning a health education program for 10-year-olds. Which setting is most likely to increase the preadolescents' participation in the program?
- A. the school classroom
- B. community center
- C. home of one of the children
- D. a local place of worship
Correct Answer: A
Rationale: The school classroom is the most suitable setting to increase preadolescents' participation in a health education program. At the age of 10, children are accustomed to the school environment, making it familiar and comfortable for them. This familiarity can help reduce anxiety and increase engagement during the program. Community centers may be less familiar and could pose distractions, potentially reducing participation. Conducting the program at the home of one of the children may lead to unequal access for other participants and may not provide the necessary facilities for an educational session. A local place of worship may not be perceived as a neutral or suitable environment for a health education program, potentially hindering participation.
The healthcare provider is preparing to administer intravenous immune globulin (IVIG) to a client with Guillain-Barre syndrome. Which assessment is most important before initiating the infusion?
- A. Lung sounds and respiratory status.
- B. Skin integrity and color.
- C. Neurological status and level of consciousness.
- D. Cardiac rate and rhythm.
Correct Answer: D
Rationale: The correct answer is D, "Cardiac rate and rhythm." Monitoring cardiac rate and rhythm is crucial before initiating IVIG because bradycardia is a common side effect associated with this therapy. Assessing lung sounds and respiratory status (Choice A) is important, but cardiac monitoring takes precedence due to the risk of bradycardia. Skin integrity and color (Choice B) are important assessments, but they are not directly related to potential complications of IVIG infusion. Neurological status and level of consciousness (Choice C) are also vital assessments, but monitoring cardiac function is more pertinent in this scenario.