Nokea
The nurse is assisting in caring for a client who had a transsphenoidal hypophysectomy 48 hours ago and has developed diabetes insipidus. Which of the following prescriptions should the nurse clarify?
- A. Administer desmopressin
- B. Check the client's urine osmolarity daily
- C. Obtain a blood specimen to check the serum sodium level
- D. Place the client in Trendelenburg position
Correct Answer: D
Rationale: Desmopressin treats diabetes insipidus by replacing vasopressin. Checking urine osmolarity and serum sodium monitors the condition. Trendelenburg position is inappropriate as it may increase intracranial pressure post-hypophysectomy.
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The nurse is discussing iron deficiency anemia with a community group. Which of the following persons are at risk for iron deficiency anemia? Select all that apply.
- A. A 15-month-old who drinks a lot of milk
- B. A 6-year-old who has sickle cell anemia
- C. An adolescent female
- D. A woman who is 8 months pregnant
- E. An African-American middle-aged man
- F. A 78-year-old on a fixed income
Correct Answer: A,C,D,F
Rationale: Toddlers drinking excessive milk, adolescent females (due to menstruation), pregnant women (increased iron demand), and elderly on fixed incomes (poor diet) are at risk. Sickle cell anemia and African-American males are not specific risk factors.
After obtaining a nutritional assessment of an elderly client, the nurse determines that the client's diet lacks sufficient protein. Which foods represent low-cost sources of protein?
- A. Potatoes and beef
- B. Peas and beans
- C. Tomatoes and beets
- D. Pork and rice
Correct Answer: B
Rationale: Peas and beans are low-cost, high-protein foods. Beef and pork are expensive, and potatoes, tomatoes, beets, and rice are low in protein.
A client with chronic pancreatitis is receiving Pancreatin. Which of the following observations is most indicative that the drug treatment is having the desired effect?
- A. The client's appetite is improved.
- B. The client's weight loss is greater than 10 pounds.
- C. The client's stools contain less fat and occur with less frequency.
- D. The client's tissue bruises less easily.
Correct Answer: C
Rationale: Pancreatin replaces pancreatic enzymes, aiding fat digestion. Reduced fat in stools and less frequent bowel movements indicate effective treatment. Appetite improvement is secondary, weight loss is undesirable, and bruising is unrelated.
The nurse is contributing to a staff education program about cancer screening. Which of the following findings should the nurse suggest including as a possible warning sign of cancer?
- A. recent diagnosis of benign prostatic hyperplasia
- B. unintentional weight loss of 15 lb (6.8 kg) over the past 3 months
- C. a doughy, mobile, golf ball-sized lesion under the skin on the thigh
- D. a fever, productive cough, and hoarseness for the past 5 days
Correct Answer: B
Rationale: Unintentional weight loss is a cancer warning sign. BPH is benign, a mobile lesion is likely benign, and cough/fever suggest infection.
The nurse is reinforcing teaching on oral care and symptom management to a client with head and neck cancer who has developed mouth sores related to external radiation therapy. Which of the following instructions should the nurse include? Select all that apply.
- A. Apply a water-soluble lubricating agent to moisturize mouth tissue
- B. Avoid hot liquids and foods that are spicy or acidic
- C. Brush your teeth with a soft-bristle toothbrush
- D. Cleanse the mouth with saline after meals and at bedtime
- E. Rinse with alcohol-based antiseptic mouthwash to decrease mouth odor
Correct Answer: A,B,C,D
Rationale: Water-soluble lubricant , avoiding irritants , soft brushing , and saline rinses promote comfort. Alcohol-based mouthwash irritates sores.