Nokea
The nurse is providing teaching to a client newly diagnosed with hypertension. The nurse knows that the client understands the teaching when the client selects which menu option?
- A. frozen pizza and a spinach salad
- B. baked chicken with fresh green beans
- C. a ham sandwich with peas and carrots
- D. a can of chicken soup and a grilled cheese sandwich
Correct Answer: B
Rationale: Baked chicken and fresh green beans are low-sodium, suitable for hypertension. Other options are high in sodium.
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A child is seen in the health care clinic, and testing for human immunodeficiency virus (HIV) is performed because of the child's exposure to HIV infection. Which home care instruction should the nurse provide to the parents of the child?
- A. Avoid sharing toothbrushes.
- B. Avoid all immunizations until the diagnosis is established.
- C. Wipe up any blood spills with a rag, and allow them to air-dry.
- D. Wash your hands with half-strength bleach if they come in contact with the child's blood.
Correct Answer: A
Rationale: Parents should avoid sharing toothbrushes to prevent potential HIV transmission through blood or bodily fluids. Immunizations should be kept up to date to protect the child. Blood spills should be cleaned with a paper towel, followed by soap and water, then a bleach solution, not just a rag and air-drying. Washing hands with soap and water is sufficient; bleach is too caustic for skin.
Two basic but important risk factors for testicular cancer are which of the following?
- A. Race
- B. Age
- C. Marital status
- D. Number of children
Correct Answer: A,B
Rationale: Two basic but important risk factors for testicular cancer are race and age. The incidence of testicular cancer is four times higher among white males than black males. It is the most common type of cancer to occur in males between the ages of 15 and 34 years. Other risk factors include a history of an undescended testis and a family history of testicular cancer. Marital status and the number of children are not risk factors for testicular cancer.
A client has been started on a monoamine oxidase inhibitor (MAOI). Which information should the nurse include when teaching the client about the medication?
- A. This medication can cause severe drowsiness.
- B. The client must avoid foods that contain tyramine.
- C. The medication is associated with a high rate of abuse.
- D. The medication will begin to alleviate symptoms of depression almost immediately.
Correct Answer: B
Rationale: MAOIs are used to treat depression. Although MAOIs usually produce hypotension as a side effect, potentially lethal hypertension can occur if the client eats foods that contain tyramine. Such foods include aged cheeses, hot dogs, and beer, among others. The medication does not cause drowsiness, is not associated with a high rate of abuse, and does not act almost immediately.
The nurse has implemented a plan of care for a client diagnosed with a cervical 5 (C5) spinal cord injury to promote health maintenance. Which client outcome indicates the effectiveness of the plan?
- A. Maintenance of intact skin
- B. Regaining of bladder and bowel control
- C. Performance of activities of daily living independently
- D. Independent transfer of self to and from the wheelchair
Correct Answer: A
Rationale: A C5 spinal cord injury results in quadriplegia with no sensation below the clavicle, including most of the arms and hands. The client maintains the partial movement of the shoulders and elbows. Maintaining intact skin is an outcome for spinal cord injury clients. The remaining options are inappropriate for this client.
Which of the following interventions is necessary before insertion of an arterial line into the radial artery?
- A. Ensure that the client does not need surgery
- B. Assess the client's grip strength
- C. Perform an Allen test
- D. Check a serum potassium level
Correct Answer: C
Rationale: Before inserting an arterial line into the radial artery, it is crucial to perform an Allen test. The Allen test assesses the collateral circulation to the hand by compressing both the radial and ulnar arteries. By occluding the radial artery and releasing the ulnar artery, the nurse can check if the ulnar artery can adequately supply blood to the hand if the radial artery is cannulated. This step ensures that there is adequate circulation to the hand post-insertion of the arterial line.
Choice A, ensuring that the client does not need surgery, is not directly related to the insertion of an arterial line and is not a necessary step before the procedure. Choice B, assessing grip strength, is not specific to the vascular status of the hand and does not provide information about the adequacy of collateral circulation. Choice D, checking a serum potassium level, is unrelated to the assessment of radial artery patency and collateral circulation, which are the primary concerns before arterial line insertion.