The nurse has attended a staff education program about various types of diets. The nurse recognizes that which diet would place a client at the highest risk for megaloblastic anemia?
- A. lactoovovegetarian
- B. lactovegetarian
- C. ovovegetarian
- D. vegan
Correct Answer: D
Rationale: A vegan diet excludes all animal products, including vitamin B12 sources, which can lead to megaloblastic anemia if not supplemented. Other diets include dairy or eggs, which provide some B12.
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The nurse is preparing teaching for a client with Parkinson disease. Which of the following techniques are appropriate when communicating with a client with Parkinson disease? Select all that apply.
- A. Encourage the client to speak slowly and pause to take deep breaths periodically
- B. Identify and promote the client's capabilities and strengths throughout the sessions
- C. Provide client teaching during times of day when the client has the most energy
- D. Reserve discussion of important or complex teaching for the client's caregiver
- E. Schedule teaching sessions at times with low risk of rushing or interruptions
Correct Answer: A,B,C,E
Rationale: Speaking slowly aids clarity, promoting strengths builds confidence, teaching during high-energy times optimizes learning, and uninterrupted sessions enhance focus. Complex teaching should include the client, not just the caregiver, to respect autonomy.
The nurse is planning care for a group of senior citizens. The nurse should plan activities that promote achievement of which developmental task?
- A. Identity
- B. Intimacy
- C. Generativity
- D. Ego integrity
Correct Answer: D
Rationale: Ego integrity, accepting one's life as meaningful, is the developmental task for seniors per Erikson's theory. Identity, intimacy, and generativity apply to younger stages.
Because a client has Addison's disease, the nurse would expect to see which of the following in the nursing assessment?
- A. A supraclavicular fat pad
- B. A puffy face
- C. Low blood pressure
- D. Ecchymotic areas
Correct Answer: C
Rationale: Addison's disease causes cortisol and aldosterone deficiency, leading to hypotension. Fat pads and puffy face are Cushing's symptoms, and ecchymosis is less specific.
The nurse is caring for a client with deep venous thrombosis of the lower extremity. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. dry, shiny, hairless skin on the affected extremity
- B. warmth and redness of the affected extremity
- C. reports of pain in the affected calf
- D. edema of the affected extremity
- E. cyanosis of the affected toes
Correct Answer: B,C,D
Rationale: DVT causes inflammation, leading to warmth, redness, pain, and edema in the affected extremity. Dry, shiny, hairless skin and cyanosis are more typical of arterial insufficiency, not DVT.
The practical nurse is assisting the registered nurse in creating a care plan for a client who is intubated, on mechanical ventilation, and receiving continuous enteral tube feedings via a small-bore nasogastric tube. Which interventions should be included to prevent aspiration in this client? Select all that apply.
- A. Check gastric residual every 12 hours
- B. Keep head of the bed at ≥30 degrees
- C. Maintain endotracheal cuff pressure
- D. Monitor for abdominal distension every 4 hours
- E. Use caution when administering sedatives
Correct Answer: B,C,D,E
Rationale: Elevating the head of the bed (≥30 degrees) reduces reflux, proper cuff pressure seals the airway, monitoring distension detects feed intolerance, and cautious sedation prevents respiratory depression. Residual checks every 4-6 hours are standard, not 12.
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