Nokea
A child with celiac disease.
The nurse is instructing the parents of a child with celiac disease. The nurse knows that teaching has been effective when the parents make which of the following statements?
- A. My child's diet should include raw vegetables, fruits, and crackers.
- B. My child's diet should be high in carbohydrates, high in calories, and high in proteins.
- C. The only restriction in my child's diet should be breads and cereals.
- D. My child's diet should be high in calories, high in protein, and restrict foods containing rye, oats, wheat, and barley.
Correct Answer: D
Rationale: Strategy: 'Teaching has been effective' indicates you are looking for a correct statement. The topic of the question is unstated. (1) does not reflect appropriate dietary needs for this child (2) does not reflect appropriate dietary needs for this child (3) does not reflect appropriate dietary needs for this child (4) correct-celiac disease is characterized by an intolerance for gluten; foods containing rye, oats, wheat, and barley should be restricted
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The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member is
- A. Advising client to restrict sodium intake
- B. Taking the blood pressure in the left arm
- C. Elevating her left arm above heart level
- D. Compressing the drainage device
Correct Answer: B
Rationale: Taking the blood pressure in the left arm. Clients who have had a unilateral mastectomy should not have their blood pressure measured on the affected side. This helps avoid the possibility of lymphedema post-operatively and in the future.
The nurse is conducting a community group discussion on nutrition. One of the participants says to the nurse, 'I am a vegan. I have been told I might get pernicious anemia. How can I prevent that?' What should the nurse include when answering the client?
- A. She is not at risk for pernicious anemia because there are many nonmeat sources of vitamin B12.
- B. She is at risk of developing pernicious anemia, but taking a vitamin supplement that contains vitamin B12 should prevent it.
- C. She should see her physician and ask about getting monthly injections of vitamin B12 because she is a risk for pernicious anemia.
- D. She should be tested for an enzyme that produces vitamin B12. If she is deficient, she should be treated with daily injections.
Correct Answer: B
Rationale: Vegans lack dietary B12 (found in animal products), risking pernicious anemia. Oral B12 supplements can prevent deficiency, while injections or enzyme testing are unnecessary unless absorption issues exist.
An 18-month-old is brought by her father to the well-baby clinic for a routine immunization. Just before the nurse gives the child the injection, the toddler begins to cry.
Which of the following comments by the nurse is the MOST appropriate?
- A. Don't cry. It will be better if you try to behave.'
- B. I know you are frightened. It will be over with soon.'
- C. A big girl like you shouldn't cry. It's only going to hurt a little.'
- D. Please stop crying. There is nothing to be afraid of.'
Correct Answer: B
Rationale: Strategy: Remember therapeutic communication (1) nontherapeutic, doesn't respond to feeling tone and tells child what to do (2) correct-doesn't minimize child's reaction, responds to feeling tone (3) nontherapeutic, minimizes child's reaction (4) nontherapeutic, minimizes child's reaction, should indicate it is OK to feel afraid
The nurse is caring for a client who is receiving a blood transfusion. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.4°F (38°C).
- B. Heart rate of 90 bpm.
- C. Respiratory rate of 18 breaths/min.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: A
Rationale: A temperature of 100.4°F during a blood transfusion suggests a transfusion reaction, such as febrile non-hemolytic reaction, requiring immediate cessation of the transfusion. Options B, C, and D are normal: heart rate 90 bpm, respiratory rate 18 breaths/min, and blood pressure 120/80 mmHg do not indicate complications.
A client on a psychiatric unit is glaring across the room and pointing a finger at empty space and yelling. What is the nurse's best response to the client's behavior?
- A. Say to him, 'There is no one there. Keep your voice down.'
- B. Escort the client to his room
- C. Restrain the client
- D. Offer PRN haloperidol (Haldol) as ordered
Correct Answer: B
Rationale: Escorting the client to a quieter space de-escalates agitation and ensures safety, addressing potential psychosis calmly.