Nokea
The nurse is assigned to care for a client being admitted with a diagnosis of cirrhosis and ascites. Which dietary measure should the nurse expect to be prescribed for the client?
- A. Sodium restriction
- B. Increased fat intake
- C. Decreased carbohydrates
- D. Calorie restriction of 1500 daily
Correct Answer: A
Rationale: If the client has ascites, sodium and possibly fluids would be restricted in the diet. The client should maintain a normal amount of fat intake. The diet should supply sufficient carbohydrates to maintain weight and spare protein. The total daily calories should range between 2000 and 3000 . The diet should provide ample protein to rebuild tissue but not an amount that will precipitate hepatic encephalopathy.
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A client with a history of depression will be participating in cognitive therapy for health maintenance. The client asks the nurse, 'How does this treatment work?' Which statement is most appropriate for the nurse to make to the client?
- A. This treatment helps you relax and develop new coping skills.'
- B. This treatment helps you confront your fears by gradually exposing you to them.'
- C. This treatment helps you examine how your past life has contributed to your problems.'
- D. This treatment helps examine how your thoughts and feelings contribute to your difficulties.'
Correct Answer: D
Rationale: Cognitive therapy is frequently used with clients who have depression. This type of therapy is based on exploring the client's personal experience. It includes examining the client's thoughts and feelings about situations and how these thoughts and feelings contribute to and perpetuate the client's difficulties and mood. The development of new coping skills, gradually confronting fears, and reviewing one's past life in relation to your current problems are not characteristics of cognitive therapy.
A client is preparing to give a stool sample for occult blood. All of the following information is part of teaching for this client EXCEPT:
- A. Avoid eating red meat for 3 days before the test
- B. Collect the stool sample from the toilet after having a bowel movement
- C. The stool does not need to be kept in a container with preservative
- D. A small part of the stool from two areas will be tested using a smear
Correct Answer: B
Rationale: When preparing to give a stool sample for occult blood testing, clients need specific instructions to ensure accurate results. It is crucial to educate clients to avoid eating red meat for at least 3 days before the test, as the blood in the meat can interfere with the test results. Clients should be informed that the stool does not need to be kept in a container with preservative as it is not required for this type of testing. Additionally, clients should be aware that a small part of the stool from two areas will be tested using a smear. However, collecting the stool sample from the toilet after having a bowel movement is not recommended as it may introduce contaminants and affect the accuracy of the test. Therefore, this information is not part of the correct teaching for the client preparing to give a stool sample for occult blood.
A client diagnosed with nephrolithiasis arrives at the clinic for a follow-up visit. The laboratory analysis of the stone that the client passed 1 week ago indicates that the stone is composed of calcium oxalate. On the basis of this analysis, the nurse should tell the client that it is best to avoid which food to minimize the risk of recurrence?
- A. Pasta
- B. Lentils
- C. Lettuce
- D. Spinach
Correct Answer: D
Rationale: Many kidney stones are composed of calcium oxalate. Foods that raise urinary oxalate excretion and predispose to stone formation include spinach, rhubarb, strawberries, chocolate, wheat bran, nuts, beets, almonds, cashews, rhubarb, and tea. Pasta, lentils, and lettuce are not high in oxalates and are generally safe for clients with calcium oxalate stones.
Which nursing intervention is most appropriate to maintain the patency of a client's nasogastric tube?
- A. Maintain a constant connection to low-intermittent suction
- B. Irrigate the tube as per physician's order
- C. Suction the mouth and nose every shift
- D. Perform a daily fecal occult blood sample
Correct Answer: B
Rationale: The correct answer is to irrigate the tube as per physician's order. A client with a nasogastric tube is at risk of the tube kinking or clotting off, which can lead to complications such as abdominal distention or vomiting. To ensure the patency of the tube, the nurse should follow the physician's orders and facility policy to irrigate the tube with water or a solution as needed. Maintaining a constant connection to low-intermittent suction (Choice A) is not typically done to maintain tube patency. Suctioning the mouth and nose every shift (Choice C) is not directly related to maintaining nasogastric tube patency. Performing a daily fecal occult blood sample (Choice D) is unrelated to maintaining the patency of a nasogastric tube.
The nurse is providing home care instructions to a client recovering from an acute inferior myocardial infarction (MI) with recurrent angina. What instruction should the nurse provide to this client?
- A. Avoid sexual intercourse for at least 4 months.
- B. Replace sublingual nitroglycerin tablets yearly.
- C. Participate in an exercise program that includes overhead lifting and reaching.
- D. Recognize the adverse effects of acetylsalicylic acid (aspirin), which include tinnitus and hearing loss.
Correct Answer: D
Rationale: After an acute MI, many clients are instructed to take an aspirin daily. Adverse effects include tinnitus, hearing loss, epigastric distress, gastrointestinal bleeding, and nausea. Sexual intercourse usually can be resumed in 4 to 8 weeks after an acute MI if the primary health care provider agrees and if the client has been able to achieve traditional parameters such as climbing two flights of steps without chest pain or dyspnea. Clients should be advised to purchase a new supply of nitroglycerin tablets every 6 months. Expiration dates on the medication bottle should also be checked. Activities that include lifting and reaching over the head should be avoided because they reduce cardiac output.