Nokea
The nurse is caring for a client whose religious background is Seventh Day Adventist (Church of GOD). Which nursing action(s) are most appropriate in terms of providing for the dietary needs of this client? Select all that apply.
- A. Providing snacks between meals
- B. Removing coffee from the breakfast tray
- C. Ensuring that there is no pork on the dinner tray
- D. A, B
Correct Answer: D
Rationale: Seventh Day Adventists typically avoid caffeine and pork, so providing snacks between meals and removing coffee from the breakfast tray are appropriate actions to meet the dietary needs of this client. Providing snacks helps ensure the client has options that align with their dietary restrictions, while removing coffee respects their avoidance of caffeine. Ensuring that there is no pork on the dinner tray is also crucial as pork is typically avoided in their diet, making choice C correct. Therefore, choices A and B are correct, making D the most appropriate selection.
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Which of the following is a specialized medical treatment and teaching facility that provides general and specialized medical and dental care and treatment?
- A. CONUS
- B. MEDCEN
- C. MEDCOM
- D. MEDDAC
Correct Answer: B
Rationale: The correct answer is B, 'MEDCEN.' A MEDCEN (Medical Center) is a specialized medical treatment and teaching facility that offers general and specialized medical and dental care. Choice A, 'CONUS,' refers to the continental United States and is not related to medical facilities. Choice C, 'MEDCOM,' stands for Medical Command, which is an administrative entity responsible for overseeing medical units, not providing direct care. Choice D, 'MEDDAC,' refers to Medical Department Activity, which is a smaller medical unit compared to a MEDCEN and may not provide the same level of specialized care.
The nurse is preparing a postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?
- A. Establish a rapport with the client to decrease embarrassment when assessing the site
- B. Encourage the client to lie in the lithotomy position twice a day
- C. Milk the tube inserted during surgery to allow the passage of flatus
- D. Digitally dilate the rectal sphincter to express old blood
Correct Answer: A
Rationale: Establishing rapport with the client is essential in postoperative care to create a trusting relationship, decrease embarrassment, and improve the client's comfort during assessments. Choice B is incorrect because the lithotomy position is not typically recommended post-hemorrhoidectomy. Choice C is incorrect because milking the tube inserted during surgery is not a standard practice after a hemorrhoidectomy. Choice D is incorrect as digitally dilating the rectal sphincter can cause harm and is not a part of routine post-hemorrhoidectomy care.
Warfarin (Coumadin) is an anticoagulant and interferes with the action of:
- A. Platelets
- B. Vitamin K
- C. Calcium
- D. Vitamin B12
Correct Answer: B
Rationale: The correct answer is B: Vitamin K. Warfarin works by inhibiting the action of vitamin K, which is crucial for the synthesis of clotting factors in the blood. By interfering with vitamin K, warfarin decreases the production of these clotting factors, thereby prolonging the time it takes for blood to clot. This is why individuals on warfarin therapy need to monitor their vitamin K intake. Choices A, C, and D are incorrect because warfarin does not directly interfere with platelets, calcium, or vitamin B12.
The nurse enters a client's room and the client is demanding release from the hospital. The nurse reviews the client's record and noted that the client was admitted 2 days ago for treatment of an anxiety disorder, and the admission was voluntary. Which intervention should the nurse initiate first?
- A. Telephone the client's family and have them persuade the client to stay
- B. Have the client read and sign all the appropriate self-discharge papers
- C. Explain to the client that he cannot leave because he asked for treatment
- D. Notify the client's healthcare provider of the client's stated intent to leave the hospital
Correct Answer: D
Rationale: The correct intervention for the nurse to initiate first is to notify the client's healthcare provider of the client's stated intent to leave the hospital. This action is crucial as it ensures that the client's care and safety are appropriately managed. Option A is not the best choice as involving the family to persuade the client may not address the client's underlying concerns. Option B is incorrect because having the client sign self-discharge papers without further assessment is not appropriate. Option C is also incorrect as the client's request for treatment does not prevent them from leaving if they are deemed competent to make that decision.
The nurse is caring for a client whose religious background is Seventh Day Adventist (Church of GOD). Which nursing action(s) are most appropriate in terms of providing for the dietary needs of this client? Select all that apply.
- A. Providing snacks between meals
- B. Excluding caffeine and pork from the client's diet
- C. Removing coffee from the breakfast tray
- D. Ensuring that there is no pork on the dinner tray
Correct Answer: B
Rationale: The correct answer is B. Seventh Day Adventists typically avoid caffeine and pork due to religious dietary restrictions. Providing snacks between meals (choice A) is not specifically related to the dietary needs of this client. While removing coffee from the breakfast tray (choice C) aligns with the client's dietary restrictions, ensuring no pork on the dinner tray (choice D) is redundant as it is already covered in the correct answer. Therefore, choices C and D are not necessary to include as separate options.