Nokea
The nurse is teaching a client with a history of lactose intolerance about dietary modifications. The nurse should tell the client to avoid:
- A. Dairy products
- B. High-fiber foods
- C. Lean meats
- D. Fresh fruits
Correct Answer: A
Rationale: Dairy products contain lactose, which causes gastrointestinal symptoms in lactose intolerance, so they should be avoided.
You may also like to solve these questions
A client with a renal failure is prescribed a low potassium diet. Which food choice would be best for this client?
- A. 1 cup beef broth
- B. 1 baked potato with the skin
- C. 1/2 cup raisins
- D. 1 cup rice
Correct Answer: D
Rationale: A low potassium diet is essential for clients with renal failure to prevent hyperkalemia. Among the options, 1 cup of rice has the lowest potassium content (approximately 50–100 mg per cup), making it the best choice. Beef broth contains moderate potassium (around 200 mg per cup), a baked potato with skin is high in potassium (about 900 mg), and raisins are also high (around 500 mg per half cup).
The nurse is caring for the client who has been in a coma for two months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife?
- A. Tell the wife that the hospital will honor her wishes regarding organ donation, but contact the organ-retrieval staff.
- B. Tell her that because her husband signed a donor card, the hospital has the right to take the organs upon the death of her husband.
- C. Explain that it is necessary for her to donate her husband's organs because he signed the permit.
- D. Refrain from talking about the subject until after the death of her husband.
Correct Answer: D
Rationale: Discussing organ donation with the wife while the client is still alive may cause distress, especially given her opposition. The nurse should refrain from raising the topic until after the client’s death, respecting her emotional state and hospital policy, which typically involves organ donation teams post-mortem.
A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?
- A. I did not get the raise because my boss does not like me.'
- B. I felt a lump in my breast 2 weeks ago. I put off getting it checked until after my sister's wedding.'
- C. My son died 3 years ago. I still cannot bring myself to clean out his room.'
- D. My husband told me this morning that he wants a divorce. I am upset, but I cannot discuss the matter with him until after my company's board meeting today.'
Correct Answer: D
Rationale: This statement is an example of adaptive rationalization. She is coping with her disappointment by rationalizing. This is adaptive because no harm is done to self or others. It is used to protect her ego. This is an example of maladaptive suppression. She is suppressing the seriousness of the lump. It is maladaptive because delaying treatment will cause harm to her. The client's actions are an example of maladaptive denial. She is denying her son's death by not facing his possessions. Until she faces his death, she cannot face reality. This is an example of adaptive suppression. She realizes the impact of her husband's statement but delays discussion until she can devote her full attention to the matter.
The most important reason to closely assess circumferential burns at least every hour is that they may result in:
- A. Hypovolemia
- B. Renal damage
- C. Ventricular arrhythmias
- D. Loss of peripheral pulses
Correct Answer: D
Rationale: Full-thickness circumferential burns are nonelastic and create an internal tourniquet effect, compromising distal blood flow in extremities or respiratory motion in the torso, leading to loss of peripheral pulses.
A patient refuses to take his dose of oral medication. The nurse tells the patient that if he does not take the medication that she will administer it by injection. The nurse's comments can result in a charge of:
- A. Malpractice
- B. Assault
- C. Negligence
- D. Battery
Correct Answer: B
Rationale: Threatening to administer medication by injection against the patient's will constitutes assault, as it involves a threat of unwanted contact.