The dietary practice that will help a client reduce the dietary intake of sodium is
- A. Increasing the use of dairy products
- B. Using an artificial sweetener in coffee
- C. Avoiding the use of carbonated beverages
- D. Using catsup for cooking and flavoring food
Correct Answer: C
Rationale: The dietary practice that will help a client reduce the dietary intake of sodium is avoiding the use of carbonated beverages. Carbonated beverages, such as sodas, contain high amounts of sodium that can contribute to increased sodium intake. By avoiding carbonated beverages, the client can effectively reduce their overall sodium consumption. Increasing the use of dairy products, using artificial sweeteners in coffee, and using catsup for cooking and flavoring food do not specifically address the reduction of sodium intake in the same way that avoiding carbonated beverages does.
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Which of the ff is a nursing intervention to ensure that the client is free from injury caused by falls?
- A. Nurse monitors for chest pain and elevated low-density lipoprotein levels
- B. Nurse monitors for swelling and heaviness of legs
- C. Nurse monitors postural changes in BP
- D. Nurse monitors temperature for mild fever
Correct Answer: B
Rationale: Monitoring for swelling and heaviness of legs is a nursing intervention that can help prevent falls. Swelling and heaviness of legs could indicate conditions such as edema or circulation problems, which may increase the risk of falls due to impaired mobility and stability. By identifying these signs early on, the nurse can intervene promptly to address the underlying issues and prevent potential falls. This proactive approach aligns with the goal of ensuring the client is free from injury caused by falls. Monitoring for chest pain and elevated low-density lipoprotein levels, postural changes in BP, or mild fever may be important for overall client care but are not directly related to fall prevention.
Compartment syndrome is a potential complication of elbow fractures that decreases circulation to local neuromuscular structures. The nurse monitors circulation on a casted elbow because irreversible damage can develop if compartment syndrome lasts for more than:
- A. 48 hours
- B. 2 hours
- C. 12 hours
- D. 24 hours
Correct Answer: D
Rationale: Compartment syndrome is a serious condition that results from increased pressure within a closed anatomical space (compartment), leading to decreased circulation to local neuromuscular structures. In the case of a casted elbow, if compartment syndrome is left untreated and persists for more than 24 hours, irreversible damage can occur. This is due to the compromised blood flow causing tissue ischemia, which can lead to permanent nerve and muscle damage. Therefore, it is crucial for healthcare providers to monitor for signs and symptoms of compartment syndrome and intervene promptly to prevent long-term complications.
In planning an educational session for a patient with HIV, the nurse would include which of the following as a method of transmission for HIV? i.Saliva iv.Semen ii.Tears v.Blood iii.Breast milk
- A. 1, 4, 2005
- B. 1, 2, 4, 5
- C. 3, 4, 2005
- D. All of the above
Correct Answer: C
Rationale: HIV can be transmitted through specific body fluids that contain the virus. Saliva, tears, and semen do not typically contain enough HIV to transmit the virus, so they are not considered significant modes of transmission. However, blood, breast milk, and genital fluids (such as semen) are known to contain higher levels of HIV and can lead to transmission of the virus. Therefore, the nurse would include blood, breast milk, and semen as methods of transmission for HIV during the educational session.
A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?
- A. Activity intolerance
- B. Impaired tissue integrity
- C. Impaired oral mucous membranes
- D. Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI
Correct Answer: D
Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to impaired clot formation and increased risk of bleeding. With a low platelet count, there is an increased risk of internal bleeding and hemorrhage, which can affect vital organs such as the brain, heart, and gastrointestinal tract. Therefore, the priority nursing diagnosis for a client with thrombocytopenia receiving chemotherapy would be Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI. Monitoring for signs of internal bleeding, such as changes in mental status, chest pain, and abdominal pain, is crucial to prevent potential life-threatening complications.
The age at which the infant can see an object, grasp it, and bring it to the mouth is
- A. 4 months
- B. 5 months
- C. 6 months
- D. 7 months
Correct Answer: A
Rationale: This milestone is typically achieved around 4 months.