Nokea
The nurse is reviewing recommended dietary modifications with the parents of a 6-month-old client with phenylketonuria. Which of the following information should the nurse include? Select all that apply.
- A. A low-phenylalanine diet is required
- B. Meat and dairy products should not be introduced into the diet
- C. Phenylketonuria is self-limiting and dietary modifications are temporary
- D. Specially prepared infant formula is necessary
- E. Tyrosine should be removed from the diet
Correct Answer: A,B,D
Rationale: Phenylketonuria requires a lifelong low-phenylalanine diet, avoiding meat and dairy, and using special formula to prevent neurological damage. It is not self-limiting, and tyrosine is needed, not removed.
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The nurse is caring for a client who was admitted for treatment of schizoaffective disorder with visual hallucinations. He tells the nurse that he sees extraterrestrials that are coming to get him. What is the best nursing response?
- A. You know that extraterrestrials are make-believe.'
- B. Call his physician and report this visual hallucination.
- C. Ignore his comment and change the subject.
- D. You think someone is coming after you?'
Correct Answer: D
Rationale: Reflecting the client's statement validates his experience without reinforcing the hallucination, promoting therapeutic communication.
An 80-year-old woman has been hospitalized for three days with pneumonia. She is now able to sit in a chair for the first time. How should the nurse plan care for today?
- A. Give her a bed bath and make her bed. Get her up in the chair later.
- B. Get her up in the chair and have her give herself a bath while the nurse makes the bed.
- C. Give her a bed bath and come back later to get her up in the chair. Make the bed while she is up in the chair.
- D. Give her a bed bath and immediately get her up in the chair so the bed can be made.
Correct Answer: C
Rationale: A bed bath conserves energy, and later chair transfer allows bed-making, optimizing rest and mobility for a recovering pneumonia patient.
The nurse has reinforced teaching with a client who has gout. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. Drink plenty of fluids, including at least 2 L of water daily
- B. Reduce your consumption of alcohol or abstain from drinking
- C. Take aspirin instead of acetaminophen for minor pain or discomfort
- D. Implement a diet and physical activity regimen to maintain a healthy weight
- E. Select protein sources that are low in purine, such as low-fat dairy products
Correct Answer: A,B,D,E
Rationale: Fluids, reduced alcohol, weight management, and low-purine proteins reduce uric acid and gout flares. Aspirin can increase uric acid levels, worsening gout, and should be avoided.
A transfusion is ordered for a hospitalized client. The charge nurse asks the LPN to start the transfusion. What should the LPN do?
- A. Start the transfusion as ordered
- B. Be sure that dextrose is hanging and then hang the blood
- C. Tell the RN that LPNs are not allowed to hang blood
- D. Hang the blood only if an IV line is already established
Correct Answer: C
Rationale: LPNs typically cannot initiate blood transfusions due to scope of practice limitations, as it requires specialized monitoring, so the LPN should inform the RN.
The nurse is caring for a child admitted with measles. Which of the following interventions should the nurse anticipate for this client? Select all that apply.
- A. Advising measles vaccination for susceptible family members
- B. Applying calamine lotion to reduce itching
- C. Placing a tracheostomy tray at the bedside
- D. Placing the client in a negative pressure isolation room
- E. Using an N95 respirator mask during client contact
Correct Answer: A,D
Rationale: Measles is highly contagious, requiring negative pressure isolation to prevent airborne spread and vaccination for susceptible contacts to prevent outbreaks. Calamine is for skin conditions like chickenpox, tracheostomy is not indicated, and N95 masks are for tuberculosis, not measles (droplet precautions).