Nokea
The nurse instructs a client 5 days after a lumbar laminectomy with spinal fusion about how to move from a supine position to standing at the left side of the bed with a walker. Which of the following directions by the nurse is BEST?
- A. Raise the head of the bed so you are sitting straight up, bend your knees, and swing your legs to the side and then to the floor
- B. Rock your body from side to side, going further each time until you build up enough momentum to be lying on your right side, and then raise your trunk toward your toes
- C. Reach over to the left side rail with your right hand, pull your body onto its side, bend your upper leg so the foot is on the bed, and push down to elevate your trunk
- D. Focus on using your arms, the left elbow as a pivot with the left hand grasping the mattress edge and the right hand pushing on the mattress above the elbow, then slide your legs over the side of the mattress
Correct Answer: C
Rationale: Choice C is the best direction provided by the nurse. This method involves reaching over to the left side rail with the right hand, pulling the body onto its side, bending the upper leg so the foot is on the bed, and pushing down to elevate the trunk. This approach helps maintain spinal alignment while moving from a lying to a standing position, reducing strain on the back. Choices A, B, and D involve movements that are not suitable for a client recovering from a lumbar laminectomy with spinal fusion and could potentially cause harm or discomfort.
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For a patient on lithium therapy, which dietary recommendation is essential?
- A. Increase caffeine intake
- B. Increase sodium intake
- C. Increase protein intake
- D. Increase fiber intake
Correct Answer: B
Rationale: The correct answer is to increase sodium intake. Maintaining consistent sodium levels is crucial for patients on lithium therapy to prevent fluctuations in drug levels. Increasing caffeine intake (Choice A) is not recommended as it can interfere with lithium levels. While protein intake (Choice C) is important, it is not the essential dietary recommendation for patients on lithium therapy. Similarly, increasing fiber intake (Choice D) is not a key recommendation for these patients.
Which of the following is a specialized medical treatment and teaching facility that provides general and specialized medical and dental care and treatment?
- A. CONUS
- B. MEDCEN
- C. MEDCOM
- D. MEDDAC
Correct Answer: B
Rationale: The correct answer is B, MEDCEN, which stands for Medical Center. A MEDCEN is a specialized medical treatment and teaching facility that provides general and specialized medical and dental care and treatment. Choices A, C, and D are incorrect. CONUS refers to the continental United States and is not a medical facility. MEDCOM stands for Medical Command, which is an organization rather than a specific facility for medical treatment. MEDDAC stands for Medical Department Activity and is also an organization responsible for medical care delivery, not a specific treatment facility.
The nurse is caring for the client recovering from a percutaneous renal biopsy. Which data indicate that the client is complying with client teaching?
- A. The client lies flat in the supine position for 12 hours
- B. The client continues oral fluids restriction while on bed rest
- C. The client's family changed the dressing on return to the room
- D. The family activates the patient-controlled analgesia pump
Correct Answer: A
Rationale: The correct answer is A. Lying flat in the supine position for 12 hours after a renal biopsy is essential to prevent bleeding and promote recovery. This position helps apply pressure to the biopsy site, reducing the risk of bleeding. Choices B, C, and D are incorrect because continuing oral fluids restriction, changing the dressing, and activating the patient-controlled analgesia pump do not directly indicate compliance with the crucial post-biopsy teaching of maintaining the supine position.
The nurse enters a client's room and the client is demanding release from the hospital. The nurse reviews the client's record and noted that the client was admitted 2 days ago for treatment of an anxiety disorder, and the admission was voluntary. Which intervention should the nurse initiate first?
- A. Telephone the client's family and have them persuade the client to stay
- B. Have the client read and sign all the appropriate self-discharge papers
- C. Explain to the client that he cannot leave because he asked for treatment
- D. Notify the client's healthcare provider of the client's stated intent to leave the hospital
Correct Answer: D
Rationale: The correct intervention for the nurse to initiate first is to notify the client's healthcare provider of the client's stated intent to leave the hospital. This action is crucial as it ensures that the client's care and safety are appropriately managed. Option A is not the best choice as involving the family to persuade the client may not address the client's underlying concerns. Option B is incorrect because having the client sign self-discharge papers without further assessment is not appropriate. Option C is also incorrect as the client's request for treatment does not prevent them from leaving if they are deemed competent to make that decision.
A client who is postpartum and has been diagnosed with iron deficiency anemia is receiving education from a nurse. Which dietary recommendation should be included in the education plan?
- A. Yogurt and mozzarella
- B. Spinach and beef
- C. Fish and cottage cheese
- D. Turkey slices and milk
Correct Answer: B
Rationale: The correct answer is B: 'Spinach and beef.' Spinach and beef are high in iron, which is crucial for treating iron deficiency anemia. Spinach is a good source of non-heme iron, while beef provides heme iron, making them effective choices to increase iron levels in the body. Yogurt and mozzarella (Choice A), fish and cottage cheese (Choice C), and turkey slices and milk (Choice D) do not contain as high iron content as spinach and beef, making them less effective in addressing iron deficiency anemia.