Nokea
The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing?
- A. Vitamin C
- B. Vitamin B1
- C. Vitamin D
- D. Vitamin A
Correct Answer: A
Rationale: Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and is essential for normal functioning of nervous tissue. Vitamin D regulates absorption of calcium and phosphorus from the GI tract and helps prevent rickets. Vitamin A is necessary for the formation and maintenance of skin and mucous membranes. It is also essential for normal growth and development of bones and teeth.
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Which behaviors are expected to be observed in the 18-month old?
- A. Has a vocabulary of 900 words
- B. Removes clothes
- C. Points to at least one named body part
- D. Asks many questions
- E. Can kick a ball forward
Correct Answer: B, C, E
Rationale: At 18 months, children remove clothes (B), point to body parts (C), and kick balls (E). Vocabulary is ~20-50 words (A), and questioning (D) emerges later (~2-3 years).
The nurse caring for a client with closed chest drainage notes that the collection chamber is full.
- A. Add more water to the suction-control chamber.
- B. Remove the drainage using a 60 mL syringe.
- C. Milk the tubing to facilitate drainage.
- D. Prepare a new unit for continuing collection.
Correct Answer: D
Rationale: A full collection chamber requires replacing the chest drainage unit to maintain effective drainage and prevent complications like tension pneumothorax.
The nurse should know that according to current thinking, the most important prognostic factor for a client with breast cancer is:
- A. Tumor size
- B. Axillary node status
- C. Client's previous history of disease
- D. Client's level of estrogen-progesterone receptor assays
Correct Answer: B
Rationale: Although tumor size is a factor in classification of cancer growth, it is not an indicator of lymph node spread. Axillary node status is the most important indicator for predicting how far the cancer has spread. If the lymph nodes are positive for cancer cells, the prognosis is poorer. The client's previous history of cancer puts her at an increased risk for breast cancer recurrence, especially if the cancer occurred in the other breast. It does not predict prognosis, however. The estrogen-progesterone assay test is used to identify present tumors being fed from an estrogen site within the body. Some breast cancers grow rapidly as long as there is an estrogen supply such as from the ovaries. The estrogen-progesterone assay test does not indicate the prognosis.
The nurse is teaching a client with a history of fibromyalgia about self-care. The nurse should tell the client to:
- A. Engage in regular exercise
- B. Avoid all physical activity
- C. Increase caffeine intake
- D. Use heating pads excessively
Correct Answer: A
Rationale: Regular, low-impact exercise can reduce pain and stiffness in fibromyalgia, improving overall function and well-being.
A client was admitted to the hospital after falling in her home. At the time of admission, her blood alcohol level was 0.27 mg%. Her family indicates that she has been drinking a fifth of vodka a day for the past 9 months. She had her last drink 30 minutes prior to admission. Alcohol withdrawal symptoms would most likely be exhibited by her:
- A. Two to 4 hours after the last drink
- B. Six to 8 hours after the last drink
- C. Immediately on admission
- D. Twenty-four hours after the last drink
Correct Answer: B
Rationale: This answer is incorrect. Alcohol withdrawal usually begins approximately 6-8 hours after the last drink. This answer is correct. It takes approximately 6-8 hours for metabolism of alcohol. This answer is incorrect. The alcohol is still in the system, as indicated by the high blood alcohol level. This answer is incorrect. Symptoms of alcohol withdrawal usually begin within 6-8 hours of the last drink.