Nokea
The nurse is counseling a client with obesity who is starting a weight reduction diet. The client reports consuming 4-5 regular cola beverages daily. Which of the following beverages should the nurse recommend as healthier substitutes? Select all that apply.
- A. Commercial fruit juice
- B. Flavored club soda
- C. Fresh vegetable juice
- D. Sports beverages
- E. Unsweetened tea
Correct Answer: B,C,E
Rationale: Flavored club soda, fresh vegetable juice, and unsweetened tea are low-calorie, healthier alternatives to cola. Fruit juice and sports drinks are high in sugar.
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All of the following women are seen in the physician's office. Which is at greatest risk for preterm labor?
- A. A primigravida who has gained 30 lb during her pregnancy
- B. A 35-year-old carrying a small baby
- C. A 21-year-old pregnant with twins
- D. A 40-year-old who has four other children
Correct Answer: C
Rationale: Multiple gestation, such as twins, significantly increases preterm labor risk due to uterine overdistension, making the 21-year-old the highest risk.
The nurse knows that a client with right-sided hemiplegia understands teaching regarding ambulation with a cane if she states:
- A. I will hold the cane in my right hand.
- B. I will advance the cane and the right leg together.
- C. I will be able to walk only by using a walker.
- D. I will hold the cane in my left hand.
Correct Answer: D
Rationale: For right-sided hemiplegia, the cane is held in the left hand to support the weaker right side. Holding it in the right hand or advancing it with the right leg is incorrect. A walker is not always necessary.
The nurse is screening clients for those at risk of developing syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should recognize that the client at highest risk for developing SIADH is a client with
- A. carpal tunnel syndrome
- B. small cell lung cancer
- C. osteomyelitis
- D. sciatica
Correct Answer: B
Rationale: Small cell lung cancer is strongly associated with SIADH due to ectopic ADH production. Other conditions listed are not significant risk factors.
A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
- A. Document the finding.
- B. Report the finding to the doctor.
- C. Prepare the client for a C C-section.
- D. Continue primary care as prescribed.
Correct Answer: B
Rationale: Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to document the finding, so answer A is incorrect. The physician must make the decision to perform a C-section, making answer C incorrect. It is not enough to continue primary care, so answer D is incorrect.
The nurse is caring for a woman whose husband beats her regularly. Which is the most important long-term goal for this woman?
- A. Provide a long-term support group
- B. Help her feel like a survivor
- C. Point out the ways she behaved
- D. Be able to blame the abuser
Correct Answer: B
Rationale: Feeling like a survivor empowers the woman, fostering resilience and self-efficacy, the most important long-term goal in domestic violence recovery.