Nokea
The nurse knows that a client understands a low residue diet when he selects which of the following from the menu?
- A. Rice and lean chicken
- B. Pasta with vegetables
- C. Strawberry pie
- D. Tuna casserole
Correct Answer: A
Rationale: The correct answer is A: Rice and lean chicken. A low residue diet aims to reduce fiber intake to ease digestion. Rice and lean chicken are low in fiber and easy to digest. Pasta with vegetables (B) contains high-fiber vegetables. Strawberry pie (C) is high in fiber due to fruit and crust. Tuna casserole (D) may contain high-fiber ingredients like noodles and vegetables. Therefore, A is the best choice for a low residue diet.
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A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
- A. Posttrauma syndrome
- B. Constipation
- C. Acute pain
- D. Anxiety
Correct Answer: C
Rationale: The most pertinent nursing diagnosis for the patient with a right femur fracture stabilized in a full leg cast is "Acute pain" (Choice C). The rationale for this is as follows:
1. The patient is experiencing moderate discomfort due to the fracture and immobilization in the cast, indicating a need for pain management.
2. Acute pain is a priority in this situation as it can impact the patient's comfort, mobility, and overall recovery.
3. Managing pain effectively is crucial for promoting healing, preventing complications, and improving the patient's quality of life.
4. Posttrauma syndrome (Choice A) may be a consideration in the long term but is not the immediate priority. Constipation (Choice B) is not the most pertinent nursing diagnosis in this scenario. Anxiety (Choice D) may be present but addressing pain is more urgent and directly related to the patient's current condition.
A client with diabetes mellitus has a prescription for 5 U-100 regular insulin and 25 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?
- A. Hyperglycemia
- B. Hyperuricemia
- C. Hypoglycemia
- D. Hypochondria
Correct Answer: C
Rationale: The correct answer is C: Hypoglycemia. At 4:30 p.m., after taking the morning insulin, the client's blood sugar may have dropped too low, leading to symptoms like headache, sweating, tremor, pallor, and nervousness. Regular insulin and NPH insulin peak at different times, causing a potential mismatch in insulin action, leading to hypoglycemia. Hyperglycemia (A) would present with different symptoms like increased thirst and urination. Hyperuricemia (B) is an excess of uric acid in the blood and does not typically present with these symptoms. Hypochondria (D) is a psychological condition and not related to the client's physical symptoms.
The nurse notes frequent muscle twitching when collecting admission data on a patient admitted for increasing muscle weakness. Which of the ff. terms should the nurse use to document this?
- A. Fasciculations
- B. Chorea
- C. Atrophy
- D. Neuropathy
Correct Answer: A
Rationale: The correct answer is A: Fasciculations. Fasciculations are involuntary muscle twitches commonly seen with neurological conditions like motor neuron disease. In this case, the patient's muscle weakness and frequent muscle twitching indicate possible nerve damage. Chorea (B) is characterized by involuntary, jerky movements, not twitching. Atrophy (C) refers to muscle wasting, not twitching. Neuropathy (D) is a general term for nerve damage and does not specifically describe the muscle twitching seen in this patient.
A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority?
- A. Assist the patient to walk in the room with crutches.
- B. Obtain a walker for the patient.
- C. Consult physical therapy.
- D. Administer pain medication.
Correct Answer: D
Rationale: The correct answer is D: Administer pain medication. The priority in this situation is to address the patient's pain and provide relief. Administering pain medication will help alleviate the discomfort and enable the patient to mobilize with crutches or a walker. Walking without pain is crucial for the patient's recovery.
Explanation for other choices:
A: Assisting the patient to walk with crutches may worsen the pain and should not be attempted until the pain is managed.
B: Obtaining a walker is not the priority as the immediate concern is addressing the patient's pain.
C: Consulting physical therapy may be beneficial in the long term, but immediate pain relief is the priority in this situation.
As the surgical incision is closed, who are the personnel in-charge in counting the needles, sponges, and instruments?
- A. the surgeon and anesthesiologist
- B. the surgeon and the registered
- C. the circulating and scrub nurse nurse first assistant
- D. the anesthesiologist and anesthetist
Correct Answer: C
Rationale: The correct answer is C - the circulating and scrub nurse first assistant. The circulating nurse is responsible for counting needles, sponges, and instruments during the closing of the surgical incision to ensure nothing is left inside the patient. The scrub nurse first assistant also plays a crucial role in this process by assisting in the counting and keeping track of the items used during the procedure. The other choices are incorrect because the surgeon and anesthesiologist (A) are not typically involved in counting items during the surgical closure, the surgeon and the registered (B) may not have the necessary training for accurate counting, and the anesthesiologist and anesthetist (D) are not directly involved in the surgical closing process.