Nokea
The nurse is caring for an elderly woman who has had a fractured hip repaired. In the first few days following the surgical repair, which of the following nursing measures will best facilitate the resumption of activities for this client?
- A. Arranging for the wheelchair
- B. Asking her family to visit
- C. Assisting her to sit out of bed in a chair qid
- D. Encouraging the use of an overhead trapeze
Correct Answer: D
Rationale: The trapeze promotes upper body strength and mobility, aiding recovery.
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Mr. Gary uses acupuncture along with his meds. This is an example of?
- A. Complementary therapy
- B. Alternative therapy
- C. Therapeutic touch
- D. Health promotion
Correct Answer: A
Rationale: Acupuncture with meds is complementary therapy (A) with conventional, per definition. Alternative (B) replaces, touch (C) hands, promotion (D) well-being not combo-specific. A fits integrated use, making it correct.
Clinitest is used to assess urine for
- A. Protein
- B. Sugar
- C. Phenylketones
- D. Bilirubin
Correct Answer: B
Rationale: Clinitest detects sugar e.g., glucose in diabetes via tablet reaction, unlike acetic (protein), PKU tests (phenylketones), or bilirubin assays. Nurses use e.g., bedside for quick checks, per diagnostics.
A client with diabetes mellitus has a prescription for Glucotrol XL (glipizide). The client should be instructed to take the medication:
- A. At bedtime
- B. With breakfast
- C. Before lunch
- D. After dinner
Correct Answer: B
Rationale: Taking Glucotrol XL with breakfast aligns with its peak action to control post-meal glucose in diabetes bedtime, pre-lunch, or post-dinner mistime it. Nurses teach this, ensuring glycemic control, vital for managing type 2 diabetes effectively.
The nurse is caring for a client with a diagnosis of cirrhosis who has developed esophageal varices. Which of the following foods should be removed from the client's diet?
- A. Custard
- B. Mashed potatoes
- C. Spinach
- D. Raisins
Correct Answer: C
Rationale: Spinach should be removed from the diet of a client with cirrhosis and esophageal varices, as its rough texture and high vitamin K content could irritate fragile varices or alter clotting, risking rupture and hemorrhage a critical concern in advanced liver disease. Custard, mashed potatoes, and raisins are softer and safer, lacking this risk. Nurses adjust diets to minimize esophageal trauma, teaching clients to avoid coarse foods, protecting against bleeding episodes that could require urgent interventions like banding or transfusion.
During a physical assessment, a client was diagnosed with increased temperature due to an increased basal metabolic rate (BMR). Which hormonal imbalances may the client have? Select all that apply.
- A. Cortisol
- B. Thyroid
- C. Estrogen
- D. Testosterone
Correct Answer: B
Rationale: Increased BMR with elevated temperature suggests thyroid (B) excess (hyperthyroidism), boosting metabolism. Cortisol (A) affects stress, not BMR primarily. Estrogen (C) and testosterone (D) influence other systems. B is correct. Rationale: Thyroid hormones (T3, T4) directly raise BMR and heat, a classic endocrine imbalance, per physiology, unlike other hormones with indirect effects.