Nokea
The nurse is developing a plan of care for the client with viral hepatitis. The nurse should instruct the client to:
- A. Obtain adequate bed rest.
- B. Increase fluid intake.
- C. Follow a high-protein diet.
- D. Avoid carbohydrates.
Correct Answer: A
Rationale: Adequate bed rest (A) supports recovery in viral hepatitis by reducing metabolic demands. Increased fluids (B) are helpful but secondary. High-protein (C) or avoiding carbohydrates (D) is not indicated.
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Which of the following instructions should the nurse include in the teaching plan for a client who is experiencing gastroesophageal reflux disease (GERD)?
- A. Limit caffeine intake to two cups of coffee per day.
- B. Do not lie down for 2 hours after eating.
- C. Follow a low-protein diet.
- D. Take medications with milk to decrease irritation.
Correct Answer: B
Rationale: Avoiding lying down for 2 hours after eating prevents reflux of stomach contents into the esophagus, a key strategy for managing GERD. The other options are incorrect or exacerbate symptoms.
A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?
- A. Elevate the head of the bed 30 to 45 degrees.
- B. Encourage the client to cough and deep breathe.
- C. Auscultate the lungs to detect abnormal breath sounds.
- D. Contact the physician.
Correct Answer: D
Rationale: Sudden dyspnea, tachypnea, and chest discomfort suggest a pulmonary embolism, a medical emergency. Contacting the physician first ensures rapid intervention. Elevating the bed, encouraging coughing, or auscultating lungs delays critical treatment.
Which of the following techniques for administering the Mantoux test is correct?
- A. Hold the needle and syringe almost parallel to the client's skin.
- B. Pinch the skin when inserting the needle.
- C. Aspirate before injecting the medication.
- D. Massage the site after injecting the medication.
Correct Answer: A
Rationale: The Mantoux test requires intradermal injection, with the needle held almost parallel to the skin to form a wheal. Pinching, aspirating, or massaging disrupts the test's accuracy.
Which of the following is the priority for a client in addisonian crisis?
- A. Controlling hypertension.
- B. Preventing irreversible shock.
- C. Preventing infection.
- D. Relieving anxiety.
Correct Answer: B
Rationale: Addisonian crisis is a life-threatening condition requiring urgent intervention to prevent irreversible shock due to adrenal insufficiency.
A client says, 'I hate the idea of being an invalid after they cut off my leg.' Which of the following would be the nurse's most therapeutic response?
- A. At least you will still have one good leg to use.'
- B. Tell me more about how you're feeling.'
- C. Let's finish the preoperative teaching.'
- D. You're lucky to have a wife to care for you.'
Correct Answer: B
Rationale: Encouraging the client to express feelings fosters coping and addresses emotional concerns.