Nokea
The nurse is teaching a client with a new colostomy about dietary choices. Which of the following foods should the nurse recommend to prevent odor and gas?
- A. Yogurt.
- B. Broccoli.
- C. Cabbage.
- D. Beans.
Correct Answer: A
Rationale: Yogurt contains probiotics that can reduce gas and odor in colostomy output, unlike broccoli, cabbage, or beans.
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Select the standardized 'hand off' change of shift reporting system that is accurately paired with its elements.
- A. SBAR: Symptoms, background, assessment and recommendations
- B. ISBAR: Interventions, symptoms, background, assessment and recommendations
- C. The Five Ps: The patient, plan, purpose, problems and precautions
- D. BATON: Background, assessment, timing, ownership and next plans
Correct Answer: C
Rationale: The Five Ps accurately describes a hand-off system with elements: patient, plan, purpose, problems, and precautions, used to ensure comprehensive communication during shift changes.
To maintain a safe milieu while addressing the needs of the cognitively impaired clients on the unit, which interventions should the psychiatric nurse implement? Select all that apply.
- A. Use distracting techniques when appropriate.
- B. Be consistently visible and available to the clients.
- C. Provide reality orientation to the clients as needed.
- D. Anticipate the needs of the clients as much as possible.
- E. Segregate potentially volatile clients from the other clients.
Correct Answer: A,B,C,D
Rationale: To maintain a safe milieu for cognitively impaired clients, the nurse should use distracting techniques to redirect inappropriate behaviors, be consistently visible and available to provide reassurance and support, provide reality orientation to help clients maintain awareness of their surroundings, and anticipate client needs to prevent distress or agitation. Segregating potentially volatile clients is not typically recommended as it may increase feelings of isolation or stigmatization; instead, managing their behavior through de-escalation and individualized care is preferred.
A client with a history of multiple sclerosis is prescribed interferon beta-1a (Avonex). The nurse should instruct the client to report which of the following side effects immediately?
- A. Flu-like symptoms.
- B. Depression.
- C. Fatigue.
- D. Injection site redness.
Correct Answer: B
Rationale: Depression is a serious side effect of interferon beta-1a, requiring immediate reporting due to the risk of worsening mental health.
The administration of an intramuscular injection to a neonate should be given in the:
- A. Gluteus maximus muscle.
- B. Vastus lateralis muscle.
- C. Deltoid muscle.
- D. The sternocleidomastoid muscle.
Correct Answer: B
Rationale: The vastus lateralis is the preferred site for IM injections in neonates due to its large muscle mass and minimal risk of nerve or bone injury.
The nurse is developing an education plan for clients with hypertension. Which of the following long-term goals is most appropriate for the nurse to emphasize?
- A. Develop a plan to limit stress.
- B. Participate in a weight reduction program.
- C. Commit to regular exercise.
- D. Monitor blood pressure regularly.
Correct Answer: D
Rationale: Regular blood pressure monitoring empowers clients to track their hypertension and adjust lifestyle or medication as needed.