Nokea
The client with atrial fibrillation is being taught about the use of Coumadin (warfarin) at home. Which of these should be emphasized to the client to avoid?
- A. Large indoor gatherings
- B. Exposure to sunlight
- C. Active physical exercise
- D. Foods rich in vitamin K
Correct Answer: D
Rationale: The correct answer is D: Foods rich in vitamin K. Foods rich in vitamin K can interfere with the effectiveness of Coumadin (warfarin) by promoting blood clotting. It is crucial for clients on this medication to maintain a consistent intake of vitamin K and avoid sudden dietary changes. Choices A, B, and C are incorrect as they are not directly related to the interaction of Coumadin (warfarin) with vitamin K. Large indoor gatherings, exposure to sunlight, and active physical exercise do not have a significant impact on the effectiveness of Coumadin (warfarin) in comparison to the interaction with foods rich in vitamin K.
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A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is
- A. High risk for infection related to vomiting
- B. Altered family processes related to chronic illness
- C. Fluid volume deficit related to vomiting
- D. Risk for aspiration related to loss of consciousness
Correct Answer: D
Rationale: Risk for aspiration is a priority concern following a seizure, especially when the child vomits, as there is a danger of aspirating the vomit into the lungs, leading to respiratory complications. The other options are not the priority in this situation. While infection risk and fluid volume deficit are important, ensuring the child's airway is clear and there is no risk of aspiration takes precedence. Altered family processes may be a concern but addressing the immediate physiological risk is the priority.
When planning the care for a young adult client diagnosed with anorexia nervosa, which of these concerns should the nurse determine to be the priority for long term mobility?
- A. Digestive problems
- B. Amenorrhea
- C. Electrolyte imbalance
- D. Blood disorders
Correct Answer: B
Rationale: The correct answer is B: Amenorrhea. Amenorrhea, or the absence of menstruation, is a common long-term consequence of anorexia nervosa due to low body weight and hormonal imbalances. Addressing amenorrhea is crucial for the patient's overall health and reproductive potential.
Choice A, Digestive problems, may also be a concern in anorexia nervosa, but in terms of long-term mobility, amenorrhea takes priority because of its impact on hormonal balance and bone health.
Choice C, Electrolyte imbalance, is important to address in anorexia nervosa due to potential cardiac complications, but it is not directly linked to long-term mobility concerns.
Choice D, Blood disorders, while they can occur in anorexia nervosa, are not as directly related to long-term mobility as amenorrhea, which can significantly affect bone health and mobility in the future.
You attended a home delivery with the Rural Health midwife. The newborn is premature. Which of the following should be included in premature infant care at home?
- A. establishing and maintaining good respiration
- B. proper management of feeding
- C. minimum handling of the baby
- D. regulation of body temperature
Correct Answer: D
Rationale: Corrected Rationale: Regulation of body temperature is crucial for the survival of a premature infant. Premature infants have difficulty regulating their body temperature, making it essential to keep them warm. While establishing and maintaining good respiration and proper feeding management are important aspects of infant care, they are not as critical as regulating body temperature for premature infants. Additionally, while minimizing handling to reduce stress can be beneficial, it is not as vital as temperature regulation for premature infants.
A client with terminal cancer is experiencing severe pain. The nurse plans to implement which of the following pain management strategies?
- A. Administer analgesics on a fixed schedule
- B. Administer analgesics only when the client requests
- C. Use non-pharmacological methods only
- D. Increase the dose of analgesics when the client complains of pain
Correct Answer: A
Rationale: Administering analgesics on a fixed schedule is the most appropriate pain management strategy for a client with terminal cancer experiencing severe pain. This approach ensures consistent pain control and helps prevent breakthrough pain. Administering analgesics only when the client requests (Choice B) may lead to uncontrolled pain as the client may delay requesting medication until the pain becomes unbearable. Using non-pharmacological methods only (Choice C) may not provide adequate pain relief for a client experiencing severe pain. Increasing the dose of analgesics when the client complains of pain (Choice D) may result in inconsistent pain control and could lead to potential overdose or adverse effects.
During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention?
- A. Pleuritic pain on inspiration
- B. Dry mucus membranes in the mouth
- C. A decrease in respiratory rate from 34 to 24
- D. Decrease in chest wall expansion
Correct Answer: D
Rationale: A decrease in chest wall expansion suggests that the client may be experiencing a serious complication, such as worsening pneumonia or respiratory failure, requiring immediate medical attention. This finding indicates a potential decrease in lung function, which could lead to respiratory distress. Pleuritic pain on inspiration may be related to the disease process but does not indicate an immediate need for intervention. Dry mucus membranes in the mouth may require attention but are not as critical as a decrease in chest wall expansion. A decrease in respiratory rate could be concerning but is not as urgent as a decrease in chest wall expansion, which directly impacts respiratory function.