Nokea
The nurse is caring for a client with a history of diverticulitis. Which of the following foods should the nurse recommend during the acute phase?
- A. Clear liquids.
- B. High-fiber foods.
- C. Red meat.
- D. Whole grains.
Correct Answer: A
Rationale: Clear liquids reduce bowel irritation during acute diverticulitis.
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A client is suspected of having a slow gastrointestinal bleed. The nurse should evaluate the client for which sign or symptom?
- A. Increased pulse.
- B. Nausea.
- C. Tarry stools.
- D. Abdominal cramps.
Correct Answer: C
Rationale: Tarry stools are a hallmark sign of a slow gastrointestinal bleed due to digested blood.
The nurse is assessing a client with suspected appendicitis. Which test should the nurse perform to confirm the diagnosis?
- A. Rovsing's sign
- B. Murphy's sign
- C. Psoas sign
- D. Both A and C
Correct Answer: D
Rationale: Rovsing's sign (pain in the right lower quadrant with left-sided pressure) and psoas sign (pain with leg extension) support an appendicitis diagnosis.
The nurse is assessing a client with a history of heart failure who is receiving a 500-mL I.V. bolus of 0.9% normal saline. To evaluate the client's response to the treatment, the nurse should especially monitor the client for which of the following?
- A. Hypotension.
- B. Increased urine output.
- C. Crackles in the lungs.
- D. Dry mucous membranes.
Correct Answer: C
Rationale: In heart failure, fluid boluses can lead to pulmonary edema, so monitoring for lung crackles is critical to detect fluid overload.
A client has a history of fibrocystic disorder of the breasts. The nurse determines that the client understands the nature of the disorder when the client states that symptoms are most likely to occur at which time?
- A. After menses
- B. Before menses
- C. In the spring months
- D. In the winter months
Correct Answer: B
Rationale: Fibrocystic breast disorder is characterized by cyclical breast pain and tenderness due to hormonal fluctuations, with symptoms most pronounced before menses when estrogen levels peak, leading to breast tissue swelling and cyst formation. Symptoms typically subside after menses. Seasonal changes, such as spring or winter months, do not influence fibrocystic breast symptoms.
What ethical principle below is accurately paired with a way that ethical principle is applied into nursing practice?
- A. Justice: Equally dividing time and other resources among a group of clients
- B. Beneficence: Doing no harm during the course of nursing care
- C. Veracity: Fully answering the client's questions without any withholding of information
- D. Fidelity: Upholding the American Nurses Association's Code of Ethics
Correct Answer: C
Rationale: Veracity is accurately paired with fully answering the client's questions without withholding information, as it emphasizes truthfulness in nursing practice. Justice involves fair treatment, not just equal time ; Beneficence involves promoting good, not just avoiding harm ; Fidelity is about keeping promises, not specifically the ANA Code .