Nokea
The nurse is caring for a client with a history of Crohn’s disease.
- A. Which dietary instruction is most appropriate for a client with Crohn’s disease?
- B. High-fiber diet during remission.
- C. Low-residue diet during exacerbations.
- D. High-fat diet to increase calories.
- E. Avoid all dairy products.
Correct Answer: B
Rationale: A low-residue diet during Crohn’s disease exacerbations reduces bowel irritation. High-fiber is used in remission, high-fat diets worsen symptoms, and dairy is avoided only if intolerant.
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The nurse is obtaining a history on a client just admitted to the unit. The client informs the nurse that any information shared with the nurse during the interview is to remain confidential.
Which of the following responses by the nurse is BEST?
- A. I'll share any information you give me with staff members only with your approval.'
- B. If the information you share is important to your care, I'll need to share it with the staff.'
- C. We can keep the information just between the two of us.'
- D. I have an obligation to maintain nurse/patient confidentiality about anything you tell me.'
Correct Answer: B
Rationale: Strategy: Think about the outcome of each answer choice. (1) the nurse has the obligation to share client information with personnel directly involved with the client's care (2) correct-the nurse is obligated to share client information with personnel directly involved with the client's care (3) the nurse must never agree to keep information confidential without knowing the content of the information (4) the nurse not obligated to report information that is not relevant to the client's care or wellbeing
The nurse is caring for a client who is receiving IV fluids at 150 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 140/90 mmHg.
- B. Heart rate of 90 bpm.
- C. Crackles in the lung bases.
- D. Urine output of 100 mL/hour.
Correct Answer: C
Rationale: Crackles in the lung bases suggest fluid overload, a serious complication of IV fluids, potentially leading to pulmonary edema. Options A, B, and D are normal or less concerning: blood pressure 140/90 mmHg and heart rate 90 bpm are stable, and urine output 100 mL/hour is adequate.
A young child is placed on droplet precautions. The nurse is caring for which of the following clients?
- A. A child with cystic fibrosis.
- B. A child with tonsillitis.
- C. A child with bronchitis.
- D. A child with pertussis.
Correct Answer: D
Rationale: droplet precautions required, private room, maintain spatial separation of 3 feet between patient and visitors
An older man is seen in the outpatient clinic for treatment of an acute attack of gout.
- A. Which nursing intervention is most beneficial for decreasing pain during ambulation in a client with gout?
- B. Perform passive range-of-motion exercises before walking.
- C. Encourage partial weight bearing while ambulating.
- D. Immobilize the extremity between activities.
- E. Restrict the amount of time and the distance the man walks.
Correct Answer: B
Rationale: Partial weight bearing reduces pressure and stress on the affected joint, alleviating gout-related pain during ambulation. Passive exercises may worsen pain, immobilization increases stiffness, and restricting walking does not address pain management during necessary movement.
While a two-day-old infant is in surgery for repair of spina bifida, the infant's mother expresses concern to the nurse because the doctor told her the infant would be confined to a wheelchair. Which of the following statements, if made by the nurse, is BEST?
- A. Physical therapy can restore the function to affected muscles.
- B. Orthopedic devices will allow your child to strengthen lower extremity muscles.
- C. Corrective surgery will return function to the affected muscles.
- D. The corrective surgery will not change your child's physical disability.
Correct Answer: D
Rationale: spinal nerves that are destroyed by the myelomeningocele cannot be corrected; nothing can return function to portions of the body that are innervated by the spinal nerves below the site of the myelomeningocele