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The healthcare provider is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the healthcare provider recommend?
- A. High protein, high calorie
- B. High carbohydrate, low fat
- C. High vitamin A, high vitamin E
- D. Fluid restricted, bland
Correct Answer: A
Rationale: The correct answer is A: High protein, high calorie. An immobilized patient with impaired skin integrity requires a diet high in protein and calories to repair injured tissue and rebuild depleted protein stores. This helps in promoting wound healing and preventing further breakdown of the skin. Choices B, C, and D are incorrect because while vitamins and minerals are essential for overall health, in this case, the priority is on providing sufficient protein and calories to support healing and recovery in an immobilized patient with impaired skin integrity.
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While auscultating a client's abdomen, a nurse hears a blowing sound over the aorta. The nurse should identify this sound as which of the following?
- A. Gallop
- B. Bruit
- C. Thrill
- D. Murmur
Correct Answer: B
Rationale: The correct answer is B: Bruit. A bruit is a blowing sound indicating turbulent blood flow, often heard over the aorta. Choices A, C, and D are incorrect. A gallop is a cardiac sound resembling the sound of a galloping horse. A thrill is a vibration felt on palpation, and a murmur is a swooshing or whooshing sound heard during auscultation of the heart or blood vessels. In this scenario, the blowing sound over the aorta specifically indicates a bruit, which signifies turbulent blood flow and should be further assessed by the healthcare provider.
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the LPN that this client understands the dietary restrictions?
- A. Tossed salad with low-sodium dressing, bacon, and tomato sandwich.
- B. New England clam chowder, unsalted crackers, fresh fruit salad.
- C. Skim milk, turkey salad, roll, and vanilla ice cream.
- D. Macaroni and cheese, diet Coke, and a slice of cherry pie.
Correct Answer: C
Rationale: The correct answer is C: Skim milk, turkey salad, roll, and vanilla ice cream. These items are low in sodium, making it a suitable meal for someone on a low-sodium diet. Skim milk, turkey salad, and vanilla ice cream are naturally low in sodium, while the roll can be selected as a low-sodium option. Choices A, B, and D contain items that are typically high in sodium, such as bacon, clam chowder, crackers, and cheese, making them unsuitable for a low-sodium diet.
A nurse is evaluating teaching about nutrition with the guardians of an 11-year-old child. Which of the following statements should indicate to the nurse an understanding of the teaching?
- A. "Our child wants to eat as much as we do, but we're afraid it will lead to becoming overweight."
- B. "Our child skips lunch sometimes, but we figure it's okay as long as we eat a healthy breakfast and dinner."
- C. "We limit fast-food restaurant meals to three times a week now."
- D. "We reward school achievements with a point system instead of pizza or ice cream."
Correct Answer: D
Rationale: The correct answer is D. Rewarding school achievements with a point system rather than food items like pizza or ice cream is a healthier approach. This choice indicates an understanding of the teaching about nutrition and the importance of not using food as a reward. Choices A, B, and C do not demonstrate a clear understanding of the teaching as they focus on concerns about overeating, skipping meals, and limiting fast-food consumption but do not address the concept of avoiding food rewards for achievements.
A client with a history of hypertension is taking a beta-blocker. Which side effect should the LPN/LVN monitor for in this client?
- A. Increased appetite
- B. Dry mouth
- C. Bradycardia
- D. Insomnia
Correct Answer: C
Rationale: The correct answer is C: Bradycardia. Beta-blockers are medications that can lower heart rate, leading to bradycardia as a potential side effect. It is essential for the LPN/LVN to monitor for this adverse effect due to the medication's mechanism of action. Choices A, B, and D are incorrect because increased appetite, dry mouth, and insomnia are not typically associated with beta-blocker use. Monitoring for bradycardia is crucial to ensure patient safety and to prevent any potential complications.
A client reports mild back pain after receiving analgesia 1 hour ago. Which non-pharmacological pain method should the nurse plan to use?
- A. Apply an ice pack to the client's back for 1 hour.
- B. Remove distractions from the client's room.
- C. Instruct the client to take deep rhythmic breaths.
- D. Encourage the client to apply a heating pad for 2 hours at a time.
Correct Answer: C
Rationale: In this scenario, the nurse should instruct the client to take deep rhythmic breaths as a non-pharmacological pain management method. Deep breathing can help the client relax, reduce stress, and manage pain effectively. Applying heat or ice for prolonged periods can lead to tissue damage. Removing distractions can be helpful for promoting relaxation but may not directly address the pain itself.