Nokea
What instruction should a nurse include when teaching a client who has recently been prescribed a low-sodium diet?
- A. Avoid foods such as smoked meats and frozen dinners.
- B. Select foods with less than 4g of sodium as indicated on food labels.
- C. Use soy sauce for flavoring foods instead of table salt.
- D. Processed and prepared foods are typically low in sodium.
Correct Answer: A
Rationale: The correct answer is A, which directs the client to avoid foods such as smoked meats and frozen dinners. These types of foods are typically high in sodium, making them unsuitable for a low-sodium diet. Option B is incorrect because foods with less than 4g of sodium might still be high in sodium for individuals on low-sodium diets. The daily recommended intake of sodium for a low-sodium diet is usually around 1.5g to 2g. Hence, 4g of sodium in a single food product can be excessive. Option C is incorrect as soy sauce, although a different source of flavor, is also high in sodium and should be used sparingly, if at all, in a low-sodium diet. Option D is incorrect because processed and prepared foods are usually not low in sodium. In fact, these foods often have high sodium content due to added salts and preservatives.
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Why does Anita stand in front of the mirror while performing a Breast Self-Examination (BSE)?
- A. To check for unusual discharges from the breast
- B. To check for any obvious malignancy
- C. To observe the size and contour of the breast
- D. To check for thickness and lumps in the breast
Correct Answer: C
Rationale: When performing a Breast Self-Examination (BSE), one of the reasons for standing in front of a mirror is to observe the size and contour of the breast (Choice C). This helps in identifying any visible changes or abnormalities such as dimpling, puckering, or changes in the size and shape of the breasts. While unusual discharges (Choice A) and thickness or lumps (Choice D) can be part of the changes a person might notice during a BSE, these are typically identified by palpation or by squeezing the nipple for discharge, not by just looking in the mirror. Choice B, checking for obvious malignancy, is too vague and not specific enough as malignancy is often not visible to the naked eye.
What effect does the use of a hot compress have, as explained to Ronnie who has been prescribed pain medication?
- A. It produces an anesthetic effect
- B. It increases nutrition in the blood to promote wound healing
- C. It increases oxygenation to the injured tissues for better healing
- D. It induces vasoconstriction to prevent infection
Correct Answer: A
Rationale: The correct answer is A: 'It produces an anesthetic effect.' Hot compresses can help alleviate pain by producing an anesthetic effect, which numbs the area. Choice B is incorrect because a hot compress does not directly increase nutrition in the blood to promote wound healing. Choice C is also incorrect because a hot compress primarily aids in pain relief rather than increasing oxygenation to the tissues for enhanced healing. Choice D is incorrect because hot compresses typically lead to vasodilation, not vasoconstriction, which aids in promoting blood flow rather than preventing infection. Safe and effective patient care relies on actions based on established nursing protocols that consider both the immediate and long-term needs of the patient.
What is the primary function of a written nursing care plan?
- A. Evaluates whether nursing care goals have been achieved
- B. Ensures the provision of quality nursing care
- C. Assists in selecting the appropriate nursing interventions
- D. Facilitates the creation of a nursing diagnosis
Correct Answer: D
Rationale: A written nursing care plan fundamentally serves to facilitate the development of a nursing diagnosis. This procedure involves analyzing patient data and identifying health problems that nurses can address independently. This analysis then aids in determining the most appropriate nursing interventions for the identified health issues. Although evaluating the achievement of nursing care goals is an important aspect, it is not the primary function of a nursing care plan. Similarly, while delivering quality nursing care is crucial, it is a broader concept that includes many other facets beyond just the initial nursing diagnosis and interventions.
When taking a blood pressure reading, where should the cuff be positioned?
- A. The cuff should be deflated fully before immediately starting a second reading for the same patient
- B. The cuff should be deflated quickly after being inflated to 180 mmHg
- C. The cuff should be large enough to wrap around the upper arm of the adult patient, positioned 1 cm above the brachial artery
- D. The cuff should be inflated to 30 mmHg above the estimated systolic BP based on palpation of the radial or brachial artery
Correct Answer: D
Rationale: When measuring blood pressure, the cuff should be inflated to 30 mmHg above the estimated systolic blood pressure based on palpation of the radial or brachial artery. This ensures an accurate blood pressure measurement. Choices A, B, and C are incorrect. Deflating the cuff fully before starting a second reading (Choice A) does not directly relate to the position of the cuff during a reading. Deflating the cuff quickly after inflating to 180 mmHg (Choice B) is not recommended because it can potentially lead to inaccurate readings. While ensuring the cuff is large enough to wrap around the upper arm positioned 1 cm above the brachial artery is important (Choice C), this alone does not guarantee an accurate blood pressure reading. The correct inflation based on palpation is the key element for accuracy, which is why Choice D is correct.
What is the primary food safety concern for a patient undergoing chemotherapy?
- A. Possible food allergy reactions
- B. Possible food-drug interactions
- C. Possible pesticide residue
- D. Potential risk of foodborne illness
Correct Answer: D
Rationale: The correct answer is D: Potential risk of foodborne illness. Patients undergoing chemotherapy have compromised immune systems, making them more susceptible to foodborne illnesses. Chemotherapy can reduce the count of white blood cells, which impairs the body's ability to fight off infections from bacteria or other pathogens that might be present in food. Therefore, the prevention of foodborne illnesses is a critical concern for these patients. Choices A, B, and C, while they represent valid concerns for food safety in general, are not the primary concern for patients undergoing chemotherapy. These patients are at a heightened risk of experiencing severe complications from foodborne illnesses, making it a more significant concern than potential food allergies, food-drug interactions, or pesticide residues.