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The nurse is caring for a client with a history of a pleural effusion who is scheduled for a thoracentesis. The nurse should:
- A. Position the client flat in bed
- B. Administer a sedative before the procedure
- C. Place the client in a sitting position
- D. Restrict fluids after the procedure
Correct Answer: C
Rationale: Sitting upright with arms supported facilitates access to the pleural space during thoracentesis and reduces complications. Sedatives and fluid restrictions are not routine.
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Because a client is taking an MAO inhibitor, it is necessary to discuss the need for adherence to a low-tyramine diet. Which of the following are foods that she should avoid?
- A. Pickled, aged, smoked, and fermented foods
- B. Fresh vegetables
- C. Broiled fresh fish and fowl
- D. Fresh fruit such as apples and oranges
Correct Answer: A
Rationale: These foods may produce elevation in blood pressure when consumed during MAO inhibition therapy. These foods have not been pickled, fermented, smoked, or aged. They contain very little, if any, tyramine or tryptophan. As long as the meat has not been aged or smoked, it is within the dietary regimen. Fresh fruits can be consumed as desired. However, the consumption of bananas is limited.
A 24-year-old graduate student recognizes that he has a phobia傳He suffers severe anxiety when he is in darkness. It has altered his lifestyle because he is unable to go to a movie theater, concert, and other events that may require absence of light. The client is seeking assistance because he is no longer able to socialize with friends due to his phobia. The psychologist working with him is using desensitization. He has asked the nursing staff to assist the client in muscle relaxation techniques. What result would indicate client education has been successful?
- A. He enters a movie theater, sits in his chair, and replaces anxiety with relaxation as the theater darkens.
- B. He enters a concert, but as the lights dim, he does not experience anxiety.
- C. He states that he no longer fears dark places.
- D. He takes a part-time job as a photographic assistant. His job necessitates his working in a darkroom.
Correct Answer: A
Rationale: This situation provides specific evidence that the client is able to integrate muscle relaxation technique into his lifestyle to alleviate anxiety. The client may not experience anxiety at the concert, but there is no evidence regarding the technique that he used to alleviate anxiety. The client may state he no longer experiences anxiety, but there is no evidence demonstrating this. He may be denying anxiety to discontinue therapy prematurely. Does he experience anxiety in the darkroom? He may have taken this job to force himself to deal with the phobia directly.
The obstetric client's fetal heart rate is 80-90 during the contractions. The first action the nurse should take is:
- A. Reposition the monitor
- B. Turn the client to her left side
- C. Ask the client to ambulate
- D. Prepare the client for delivery
Correct Answer: B
Rationale: A fetal heart rate of 80-90 during contractions indicates bradycardia possibly from cord compression or uteroplacental insufficiency. Turning the client to her left side improves placental perfusion and is the first action.
A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:
- A. Uses an electric blanket at night
- B. Dresses in extra layers of clothing
- C. Applies a heating pad to her feet
- D. Takes a hot bath morning and evening
Correct Answer: B
Rationale: Dressing in extra layers is a safe, effective way to manage cold intolerance in hypothyroidism by conserving body heat. Electric blankets and heating pads pose burn risks, and baths are temporary.
A 45-year-old client has a permanent colostomy. Which of the following foods should he avoid?
- A. Peanut butter and jelly sandwich and milk
- B. Corn beef and cabbage and boiled potatoes
- C. Oatmeal, whole-wheat toast, and milk
- D. Tuna on whole-wheat bread and iced tea
Correct Answer: B
Rationale: Gas-forming foods such as cabbage should be avoided.