Nokea
The nurse is providing dietary instructions for a client with iron-deficiency anemia. Which food is a poor source of iron?
- A. Tomatoes
- B. Legumes
- C. Dried fruits
- D. Nuts
Correct Answer: A
Rationale: Tomatoes are a poor source of iron compared to legumes, dried fruits, and nuts, which are rich in iron. Tomatoes provide vitamin C, which aids iron absorption, but lack significant iron content.
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The health team needs to realize that the compulsive concern with cleanliness that a client with severe anxiety exhibits is most likely an attempt to:
- A. Reduce his anxiety
- B. Avoid going to psychotherapy
- C. Manipulate the health team members
- D. Increase his self-image by showing higher standards than the fellow clients
Correct Answer: A
Rationale: These behaviors are attempts to relieve anxiety, as compulsive actions often serve as a coping mechanism for severe anxiety.
The nurse is caring for a client with a suspected fractured hip. Which intervention is most appropriate?
- A. Encourage ambulation to promote healing.
- B. Apply a warm compress to reduce pain.
- C. Immobilize the leg to prevent further injury.
- D. Administer aspirin for pain relief.
Correct Answer: C
Rationale: Immobilizing the leg prevents further injury and displacement in a suspected hip fracture. Amb
A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks' postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is:
- A. Autonomic dysreflexia
- B. Bradycardia
- C. Central cord syndrome
- D. Spinal shock
Correct Answer: A
Rationale: Autonomic dysreflexia, a life-threatening exaggerated sympathetic response, can occur in spinal cord injuries above T6, causing severe hypertension.
During morning assessments, the nurse finds that a client's nephrostomy tube has been clamped. The nurse's first action should be to:
- A. Assess the drainage bag.
- B. Check for bladder distention.
- C. Unclamp the tubing.
- D. Irrigate the tubing.
Correct Answer: C
Rationale: Unclamping the nephrostomy tube is the priority to restore urine flow and prevent complications like hydronephrosis or infection.
A client has been diagnosed with thrombophlebitis. She asks, 'What is the most likely cause of thrombophlebitis during my pregnancy?' The nurse explains:
- A. Increased levels of the coagulation factors and a decrease in fibrinolysis
- B. An inadequate production of platelets
- C. An inadequate intake of folic acid during pregnancy
- D. An increase in fibrinolysis and a decrease in coagulation factors
Correct Answer: A
Rationale: During pregnancy, the potential for thromboses increases owing to the increased levels of coagulation factors and a decrease in the breakdown of fibrin.