Nokea
The nurse is caring for a client with bipolar I disorder who is experiencing an acute manic episode. Which of the following meals would be appropriate to offer the client?
- A. Baked sweet potato, kale, wheat roll, water
- B. Chicken nuggets, almonds, apple slices, milk
- C. Vegetable soup, fresh salad, dinner roll, iced tea
- D. Spaghetti with meatballs, fruit salad, sliced bread, coffee
Correct Answer: A
Rationale: A simple meal like sweet potato, kale, wheat roll, and water minimizes stimulation and is easy to eat during mania. Other meals are more complex or contain caffeine (coffee, tea), which can exacerbate symptoms.
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The nurse is assessing a client with delayed wound healing. Which of the following risk factors is most important in this situation?
- A. Glucose level of 120
- B. History of myocardial infarction
- C. Long term steroid usage
- D. Diet high in carbohydrates
Correct Answer: C
Rationale: Long term steroid usage. Steroids delay wound healing by impairing the inflammatory response.
What nursing action is essential when oxygen is ordered for a client who is living at home?
- A. Assist the client and family in checking all electrical appliances in the vicinity for frayed cords.
- B. Encourage the client and family to purchase fire extinguishers.
- C. Remove electrical devices from the room where oxygen is in use.
- D. Encourage the client and family to carpet the client's room.
Correct Answer: A
Rationale: Checking for frayed cords reduces fire risk, as oxygen supports combustion. Extinguishers are secondary, removing devices is impractical, and carpeting increases static sparks.
The nurse is reinforcing information for a client with chronic obstructive pulmonary disease. Which statements by the client indicate an understanding of the pursed-lip breathing technique? Select all that apply.
- A. I exhale for 2 seconds through pursed lips
- B. I exhale for 4 seconds through pursed lips
- C. I inhale for 2 seconds through my mouth
- D. I inhale for 2 seconds through my nose, keeping my mouth closed
- E. I inhale for 4 seconds through my nose, keeping my mouth closed
Correct Answer: B,D
Rationale: Pursed-lip breathing involves inhaling 2 seconds through the nose (mouth closed) and exhaling 4 seconds through pursed lips to prolong exhalation and reduce air trapping in COPD.
The nurse is reinforcing discharge instructions with a client following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome? Select all that apply.
- A. Add high-protein foods to diet
- B. Consume high-carbohydrate meals
- C. Eat small, frequent meals
- D. Increase intake of fluids with meals
- E. Lie down after eating
Correct Answer: A,C
Rationale: High-protein foods and small, frequent meals slow gastric emptying, preventing dumping syndrome. High-carb meals and fluids with meals speed emptying, and lying down delays digestion, worsening symptoms.
A 79-year-old client asks the nurse if she needs any shots. She reports having had 'all the usual shots when I was younger.' Which immunization is most important for this person to receive?
- A. DPT
- B. MMR
- C. Pneumovax
- D. HiB
Correct Answer: C
Rationale: Pneumovax is critical for adults over 65 to prevent pneumococcal pneumonia, a significant risk in the elderly.