Nokea
The nurse is preparing a client with gout for discharge. Which dietary selection reflects an understanding of the client's condition?
- A. Broiled chicken, rice, and iced tea
- B. Sardines, lima beans, and red wine
- C. Hamburger, fries, and a milkshake
- D. Shrimp, spinach, and beer
Correct Answer: A
Rationale: Broiled chicken, rice, and iced tea suit gout, avoiding purine-rich foods (sardines, shrimp) or alcohol (wine, beer) that raise uric acid lima beans and spinach also contribute less but aren't ideal. Nurses teach this, reducing flare-ups, supporting joint health and client compliance.
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A client with a spinal cord injury suddenly develops a throbbing headache, nasal congestion, and a blood pressure of 210/110 mm Hg. Which action should the nurse perform first?
- A. Administer a prescribed antihypertensive
- B. Check the client's bladder for distention
- C. Place the client in a supine position
- D. Notify the healthcare provider
Correct Answer: B
Rationale: Symptoms (headache, congestion, BP 210/110) indicate autonomic dysreflexia; checking bladder distention (B) identifies the trigger first. Medication (A) or supine (C) is secondary. Notification (D) follows. B is correct. Rationale: Removing the stimulus (e.g., bladder) halts dysreflexia, a priority per SCI protocols, preventing hypertensive crisis.
A nurse provides care to clients of a community clinic that serves a large immigrant population. Which intervention reflects primary prevention for this group?
- A. Screening for tuberculosis
- B. Providing vaccinations
- C. Referring clients with hypertension to a specialist
- D. Teaching clients with diabetes foot care
Correct Answer: B
Rationale: Primary prevention stops illness before it starts, vital for immigrants facing unique risks. Providing vaccinations like measles or flu shots builds immunity, preventing outbreaks in a group often under-vaccinated due to access or prior country norms, a top nursing action in clinics. Screening for tuberculosis is secondary, catching disease early, common in immigrant health but not preventive. Referring hypertension cases or teaching diabetic foot care is tertiary, managing existing conditions, not averting onset. Vaccinations align with primary prevention's proactive stance data shows they cut infectious disease rates in such populations addressing environmental and social vulnerabilities. Nursing leverages this to protect community health, ensuring immigrants, often in crowded settings, dodge preventable illnesses, a practical, impactful step for this clinic's focus.
Which technique would be best in caring for a client following receiving a diagnosis of a stage IV tumor in the brain?
- A. Offering the client pamphlets on support groups for brain cancer
- B. Asking the client if there is anything he or his family needs
- C. Reminding the client that advances in technology are occurring everyday
- D. Providing accurate information about the disease and treatment options
Correct Answer: D
Rationale: Accurate information empowers the client and family to make informed decisions.
The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?
- A. Apical
- B. Radial
- C. Pedal
- D. Femoral
Correct Answer: C
Rationale: Pedal pulse absence is normal in 10-20% of people and less critical initially.
Which of the following is considered as an example of intentional tort?
- A. Malpractice
- B. Negligence
- C. Breach of duty
- D. False imprisonment
Correct Answer: D
Rationale: False imprisonment, an intentional tort, involves deliberately restricting someone's freedom, like restraining a competent patient against their will. Malpractice and negligence are unintentional torts, stemming from carelessness or failure to meet standards, not intent. Breach of duty is a negligence component, not a standalone tort. In nursing, intentional torts require purposeful action, and false imprisonment risks legal liability, emphasizing patient rights and consent in care delivery.