Nokea
The nurse is assessing the female client who is 65 inches tall and has a small body frame. Based on the information in the chart illustrated, what is the client's approximate ideal body weight?
Correct Answer: 117
Rationale: Height is 5'5†(65/ 12 = 5 remainder 5). Formula: 105 lb for 5 ft + 5 lb × 5 = 130 lb. Small frame subtracts 10% (130 × 0.1 = 13 lb). 130 − 13 = 117 lb.
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Which of the following foods present a problem for a client diagnosed with Celiac Disease?
- A. Butter
- B. Oats or barley cereal
- C. Fresh vegetables
- D. Coffee or tea
Correct Answer: B
Rationale: Celiac disease, or celiac sprue, is a malabsorption disorder affecting the small intestine in which there is a problem with the ingestion of gluten, a protein normally found in grain products such as wheat, rye, oats, or barley. The other choices reflect substances that do not contain gluten and should not pose problems for a client with this disorder.
The nurse is teaching the client, who is 24 hours post abdominal surgery, how to use an IS. Which instructions should the nurse include in the teaching? Select all that apply.
- A. Inhale slowly and deeply through mouth
- B. Seal lips tightly around mouthpiece
- C. After inhaling, hold breath for 2 to 3 seconds
- D. Sit with the HOB down and bed almost flat
- E. Splint the incision with pillows
- F. Exhale forcefully, fast, and hard
Correct Answer: A,B,C,E
Rationale: A: Deep inhalation maximizes alveolar inflation. B: Sealing prevents air leaks. C: Holding breath enhances lung expansion. E: Splinting reduces pain, aiding inhalation. D: High Fowler's position is optimal. F: Slow exhalation prevents hyperventilation.
A client's postoperative pain seems to be getting worse instead of better. When the nurse asks the client, 'Why do you think it's getting worse?' the client replies, 'My wife died last month. It's all I can think about.' The nurse must now consider:
- A. calling the physician for an increased dosage of pain medication
- B. calling the physician for a sedative
- C. referring the client for a psychiatric consult
- D. developing interventions for grief and loss
Correct Answer: D
Rationale: The client's grief over his wife's death is likely exacerbating his pain perception, requiring grief and loss interventions to address the affective component.
The greatest time savers when planning client care include all of the following except:
- A. reacting to the crisis of the moment.
- B. setting goals.
- C. planning.
- D. specifying priorities.
Correct Answer: A
Rationale: The greatest time-savers when planning client care are activities that facilitate focus and completion of priority items. Time-savers include setting goals, establishing priorities, planning tasks, delegating where appropriate, re-assessment, and ongoing evaluation of needs.
Which of the following is least relevant when reviewing the client's risk for elimination impairment?
- A. current medications
- B. ambulation abilities
- C. family history
- D. hydration status
Correct Answer: C
Rationale: The client's family history is least relevant when determining the risk for elimination impairment.