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The nurse is teaching a health class about theChooseMyPlateprogram. Which guidelines will thenurse include in the teaching session?
- A. Balancing sodium and potassium
- B. Decreasing water consumption
- C. Increasing portion size
- D. Balancing calories
Correct Answer: D
Rationale: The correct answer is D, balancing calories. This is because the ChooseMyPlate program emphasizes the importance of maintaining a balance between the calories consumed and calories expended for overall health and weight management. By balancing calories, individuals can ensure they are meeting their nutritional needs without overeating or consuming excess calories.
A: Balancing sodium and potassium is important for managing blood pressure, but this is not a specific guideline of the ChooseMyPlate program.
B: Decreasing water consumption is not a guideline of the ChooseMyPlate program. Adequate hydration is essential for overall health.
C: Increasing portion size is not recommended in the ChooseMyPlate program. It emphasizes portion control and eating appropriate serving sizes of different food groups.
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Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately?
- A. The malleus can be visualized during otoscopic examination.
- B. The tympanic membrane is pearly gray.
- C. Tenderness is reported by the patient when the mastoid area is palpated.
- D. Clear, watery fluid is draining from the patients ear.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Clear, watery fluid draining from the ear post-accident indicates a possible cerebrospinal fluid (CSF) leak, a serious condition requiring immediate medical attention to prevent complications such as meningitis.
2. CSF leak can result from a basilar skull fracture, common in head injuries like motorcycle accidents.
3. Prompt reporting of this finding by the nurse is crucial for timely intervention and prevention of potential life-threatening complications.
Summary:
A: Visualizing the malleus during otoscopic examination is normal and not an immediate concern in this scenario.
B: A pearly gray tympanic membrane is a normal finding and does not indicate a serious issue post-accident.
C: Tenderness in the mastoid area may suggest injury but is not as urgent as clear, watery fluid drainage indicative of a CSF leak.
The nurse is teaching a patient preventative measures regarding vaginal infections. The nurse should include which of the following as an important risk factor?
- A. High estrogen levels
- B. Late menarche
- C. Nonpregnant state
- D. Frequent douching
Correct Answer: D
Rationale: The correct answer is D: Frequent douching. Douching disrupts the natural balance of vaginal flora, making the environment more susceptible to infections. High estrogen levels (A) can actually protect against vaginal infections. Late menarche (B) and nonpregnant state (C) are not direct risk factors for vaginal infections. In summary, frequent douching is the most significant risk factor as it disrupts the vaginal microbiome.
In providing prenatal care to a pregnant patient, what does the nurse teach the expectant mother?
- A. Calcium intake is especially important in the first trimester.
- B. Protein intake needs to decrease to preserve kidney function.
- C. Folic acid is needed to help prevent birth defects and anemia.
- D. Extra vitamins and minerals should be taken as much as possible.
Correct Answer: C
Rationale: The correct answer is C because folic acid is crucial in preventing neural tube defects and anemia in the developing fetus. The nurse should teach the expectant mother about the importance of taking folic acid supplements before and during pregnancy. Folic acid is essential for proper cell division and growth, reducing the risk of birth defects.
Choice A is incorrect because calcium intake is important throughout pregnancy, not just in the first trimester. Choice B is incorrect as protein intake should be adequate to support maternal and fetal growth, not decreased. Choice D is incorrect as excessive intake of vitamins and minerals can be harmful to the mother and the baby.
In summary, the expectant mother should be educated on the importance of folic acid supplementation to prevent birth defects and anemia, while also ensuring a balanced diet with all essential nutrients.
A patient newly diagnosed with cancer is scheduled to begin chemotherapy treatment and the nurse is providing anticipatory guidance about potential adverse effects. When addressing the most common adverse effect, what should the nurse describe?
- A. Pruritis (itching)
- B. Nausea and vomiting
- C. Altered glucose metabolism
- D. Confusion
Correct Answer: B
Rationale: The correct answer is B: Nausea and vomiting. Chemotherapy commonly causes gastrointestinal side effects, such as nausea and vomiting, due to its impact on rapidly dividing cells in the digestive tract. This adverse effect can significantly impact a patient's quality of life and adherence to treatment. Pruritis (A), itching, is less common and usually not a primary side effect of chemotherapy. Altered glucose metabolism (C) is a potential effect of some chemotherapeutic agents but is not the most common adverse effect. Confusion (D) is not typically associated with chemotherapy and is more commonly seen with other medications or medical conditions.
A patient who is receiving care for osteosarcoma has been experiencing severe pain since being diagnosed. As a result, the patient has been receiving analgesics on both a scheduled and PRN basis. For the past several hours, however, the patients level of consciousness has declined and she is now unresponsive. How should the patients pain control regimen be affected?
- A. The patients pain control regimen should be continued.
- B. The pain control regimen should be placed on hold until the patients level of consciousness improves.
- C. IV analgesics should be withheld and replaced with transdermal analgesics.
- D. The patients analgesic dosages should be reduced by approximately one half. Chapter 36: Immune : HIV/AIDS: stages, testing, complications, assessment; care & Safe Sexual practices
Correct Answer: C
Rationale: The correct answer is C. When a patient's level of consciousness declines and becomes unresponsive, it may indicate a potential overdose of analgesics. To ensure patient safety, IV analgesics should be withheld and replaced with transdermal analgesics, which provide a more controlled and gradual release of medication. This switch helps prevent further overdose and adverse effects. Continuing the current pain control regimen (Choice A) may worsen the situation. Placing the pain control regimen on hold (Choice B) may lead to inadequate pain management. Reducing analgesic dosages (Choice D) may not be sufficient in addressing the overdose issue.