Nokea
The nurse is planning dietary counseling for the client with chronic heart failure taking triamterene. The nurse plans to include which item in a list of foods that are acceptable?
- A. Bananas
- B. Oranges
- C. Baked potato
- D. Canned pears
Correct Answer: D
Rationale: Triamterene is a potassium-retaining diuretic, so high-potassium foods like bananas, oranges, and potatoes should be avoided. Canned pears are lower in potassium, making them acceptable.
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The nurse is caring for a client who is a survivor of a disaster event. The client begins to display behaviors not demonstrated before. Which manifestations should indicate to the nurse that the client may be experiencing post-traumatic stress disorder (PTSD)? Select all that apply.
- A. Irritability and sleep disturbances
- B. Flashbacks or recollections of the disaster
- C. Regression to an earlier developmental stage
- D. A feeling of estrangement or detachment from others
- E. Consistent discussion and rationalizing as to why the disaster occurred
- F. Repression or the inability to remember an important aspect associated with the disaster
Correct Answer: A,B,D,F
Rationale: PTSD involves recurrent flashbacks, irritability, sleep disturbances, estrangement, and repression of trauma-related memories. Regression and rationalizing the event's cause are not typical PTSD symptoms. These manifestations indicate a sustained maladaptive response to the traumatic event, often with avoidance of trauma-related stimuli and psychological distress.
The nurse provides instructions to a new mother who is about to breastfeed her newborn infant. The nurse observes the new mother as she breastfeeds for the first time and determines the mother needs further teaching if the new mother applies which technique?
- A. Turns the newborn infant on his side, facing the mother
- B. Tilts up the nipple or squeezes the areola, pushing it into the newborn's mouth
- C. Draws the newborn the rest of the way onto the breast when the newborn opens his mouth
- D. Places a clean finger in the side of the newborn's mouth to break the suction before removing the newborn from the breast
Correct Answer: B
Rationale: The mother should avoid tilting up the nipple or squeezing the areola and pushing it into the newborn's mouth, as this can lead to improper latch or difficulties with milk flow. Turning the newborn on his side facing the mother, drawing the newborn onto the breast when the mouth opens, and breaking suction with a clean finger are appropriate breastfeeding techniques.
A nurse is caring for a client with dumping syndrome. Which statement by the client indicates a need for further teaching?
- A. I should lie down after I eat my meals.
- B. I may experience weakness and dizziness.
- C. I should eat a low-fat, high-protein, low-carbohydrate diet.
- D. I should eat small meals and avoid drinking fluids with my meals.
Correct Answer: C
Rationale: Dumping syndrome requires a high-fat, low-carbohydrate diet to slow gastric emptying. Other statements are correct.
The nurse is caring for a pregnant client at 24 weeks. The client voids before the nurse measures the fundal height. Which finding by the nurse would be expected in assessment of this client?
- A. a fundal height of 22 to 26 cm
- B. a fundal height of 27 to 30 cm
- C. a fundal height of 29 to 33 cm
- D. a fundal height of 31 to 34 cm
Correct Answer: A
Rationale: At 24 weeks, fundal height typically measures 22-26 cm, corresponding to gestational age in centimeters.
The nurse is participating in a free community health screening with a group of student nurses. Which statement by a student nurse requires further teaching by the licensed nurse?
- A. Colorectal cancer screening should begin at age 50.
- B. Men should have a prostate-specific antigen test starting at age 55.
- C. High-density lipoprotein should be greater than 50 mg/dL for women.
- D. Risk factors for hypertension include being over age 60 and leading a sedentary lifestyle.
Correct Answer: B
Rationale: Prostate-specific antigen testing typically starts at age 50, not 55, for average-risk men. Other statements are accurate.