Nokea
The nurse should utilize data about which of the following to provide information about the nutritional status of a client being evaluated for malnutrition?
- A. triceps skinfold measurement
- B. fasting blood glucose level
- C. hemoglobin A1c level
- D. serum lipid profile results
Correct Answer: A
Rationale: Objective anthropometric measurements such as triceps skinfold and mid-arm circumference (MAC), along with weight, are usually used to diagnose malnutrition. While all the other choices represent tests that might provide useful information, they also might be affected by variables other than malnutrition.
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Which of the following coping mechanisms protects an individual from anxiety?
- A. denial and fantasy
- B. rationalization and suppression
- C. regression and displacement
- D. reaction formation and projection
Correct Answer: A
Rationale: Denial and fantasy reduce anxiety by avoiding or reimagining reality, serving as protective coping mechanisms, unlike the other options, which may not consistently reduce anxiety.
A person using over-the-counter nasal decongestant drops who reports unrelieved and worsening nasal congestion should be instructed to:
- A. switch to a stronger dose of the medication.
- B. discontinue the medication for a few weeks.
- C. continue taking the same medication, but use it more frequently.
- D. use a combination of medications for better relief.
Correct Answer: B
Rationale: Prolonged use of decongestant drops (3 to 5 days) can lead to rebound congestion, which is relieved by discontinuing the medication for 2 to 3 weeks. Nasal congestion results from dilation of nasal blood vessels due to infection, inflammation, or allergy. With this dilation, there is a transudation of fluid into the tissue spaces, resulting in swelling of the nasal cavity. Nasal decongestants (sympathomimetic amines) stimulate the alpha-adrenergic receptors, producing vascular constriction (vasoconstriction) of the capillaries within the nasal mucosa. The result is shrinking of the nasal mucous membranes and a reduction in fluid secretion (runny nose). Decongestants can make a client jittery, nervous, or restless. These side effects decrease or disappear as the body adjusts to the drug. When nasal decongestants are used for longer than 5 days, instead of the nasal membranes constricting, vasodilation occurs, causing increased stuffy nose and nasal congestion. The nurse should emphasize the importance of limiting the use of nasal sprays and drops. As with any alpha-adrenergic drug (for example, decongestants), blood pressure and blood glucose levels can increase. These drugs are contraindicated and should only be used with extreme caution for clients with hypertension, cardiac disease, hyperthyroidism, and diabetes mellitus.
A client is 36 hours post-op a TKR surgery, 270 cc's of sero-sanguinous accumulates in the surgical drains. What action should the nurse take?
- A. Notify the doctor
- B. Empty the drain
- C. Do nothing
- D. Remove the drain
Correct Answer: A
Rationale: The physician should be notified if excessive drainage is noted from the surgical site.
Which of the following lab values would indicate symptomatic AIDS in the medical chart? (T4 cell count per deciliter)
- A. Greater than 1000 cells per deciliter
- B. Less than 500 cells per deciliter
- C. Greater than 2000 cells per deciliter
- D. Less than 200 cells per deciliter
Correct Answer: D
Rationale: A T4 cell count less than 200 cells per deciliter indicates symptomatic AIDS, as it reflects severe immunosuppression.
Which intervention should the nurse take first to assist a woman who states that she feels incompetent as the mother of a teenage daughter?
- A. Recommend that she discipline her daughter more strictly and consistently.
- B. Make a list of things her husband can do to help her improve.
- C. Assist the mother to identify what she believes is preventing her success and what she can do to improve.
- D. Explore with the mother what the daughter can do to improve her behavior.
Correct Answer: C
Rationale: The intervention priority with a mother who feels incompetent to parent a teenage daughter is to assist the mother to identify what she feels her crisis events are and to help her develop better coping skills and improve her mothering skills. With a teenager, the growth and development parameters have to be concentrated on self as well as acquiring an added event. Choices 1, 2, and 4 do not directly address the mother's feelings of inadequacy.