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The nurse instructs a client who is hospitalized and on a low-fat diet. Which menu does the nurse provide for the client?
- A. Shrimp, avocado, and tomato salad
- B. Calf's liver, potato salad, and sherbet
- C. Lean steak, mashed potatoes, and gravy
- D. Turkey breast, boiled rice, and strawberries
Correct Answer: D
Rationale: Turkey breast without the skin, boiled rice, and strawberries offer the client nourishing foods that are low in fat. Some sources of fat include meats, avocado, salad dressing, mayonnaise, butter, cheese, and bacon. The remaining options contain high-fat foods.
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The nurse is teaching dietary modifications to the client with hypertension. The nurse should instruct the client to eat which snack foods?
- A. Raw carrots
- B. Celery stalks
- C. Frozen pizza
- D. Cheese and crackers
- E. Canned tomato soup
Correct Answer: A,B
Rationale: Sodium should be avoided by the client with hypertension. Fresh fruits and vegetables such as carrots and celery are naturally lower in sodium. Hypertensive clients are also advised to keep fat intake to less than 30% of their total calories as part of prudent heart living. Each of the incorrect options contains high amounts of sodium, and frozen pizza and cheese and crackers are also likely to be higher in fat.
The nurse is performing a socioeconomic assessment of an Asian client. Which questions are appropriate for the nurse to ask?
- A. What do you do for a living?
- B. How much money do you make yearly?
- C. Do you have a primary health care provider?
- D. How many years of school did you complete?
- E. How different is your life here from in your homeland?
- F. What type of work did you do back in your homeland?
Correct Answer: A,C,D,E,F
Rationale: Aspects to include in a cultural assessment include biocultural history and socioeconomic status (distinct health risks can be attributed to the ecological and socioeconomic context of the culture) and the client's country of origin. Other aspects to assess include religious and spiritual beliefs, communication patterns, time orientation, caring beliefs and practices, and previous experiences with professional health care. Some specific questions to ask when performing a socioeconomic assessment are noted in the correct options. Asking the client about his or her yearly income is inappropriate, unnecessary, and unrelated to health care resources.
The nurse is instructing a client diagnosed with type 1 diabetes mellitus about the management of hypoglycemic reactions. The nurse instructs the client that hypoglycemia most likely occurs during what time interval after insulin administration?
- A. Peak
- B. Onset
- C. Duration
- D. Anytime
Correct Answer: A
Rationale: Insulin reactions are most likely to occur during the peak time after insulin administration, when the medication is at its maximum action. Peak action depends on the type of insulin, the amount administered, the injection site, and other factors.
The nurse provides information to a client about performing a breast self-examination (BSE). The nurse determines that the client needs additional teaching if the client makes which statements? Select all that apply.
- A. The BSE must be done monthly.
- B. Lumps in my armpit area are normal.
- C. I can palpate my breasts with soapy water while showering.
- D. I should perform the examination on the day that I start my period.
- E. When I squeeze my nipples, I should expect to note some discharge.
- F. I should stand before a mirror and inspect each breast for anything unusual.
Correct Answer: B,D,E
Rationale: Any lumps in the armpit or nipple discharge are abnormal and require reporting to a healthcare provider. The BSE should be performed 2 to 3 days after menstruation ends, not on the first day, when breasts are tender. Monthly BSE, palpation with soapy water in the shower, and mirror inspection are correct techniques.
The nurse assesses a client with hepatic encephalopathy for the presence of asterixis. What should the nurse do to appropriately test for asterixis?
- A. Examine the client's handwriting movements.
- B. Check the stool for clay-colored pigmentation.
- C. Ask the client to extend the wrist and the fingers.
- D. Check the serum bilirubin and liver enzyme levels.
Correct Answer: C
Rationale: Asterixis, or liver flap, is a rapid, nonrhythmic tremor in hepatic encephalopathy, tested by having the client extend the wrist and fingers. Handwriting is nonspecific, stool color is unrelated, and lab tests do not assess asterixis directly.