Nokea
The nurse teaches a client at risk for coronary artery disease about lifestyle changes needed to reduce his risks. The nurse determines that the client understands these necessary lifestyle changes if the client makes which statements?
- A. I will attempt to stop smoking.
- B. I will be sure to include some exercise such as walking in my daily activities.
- C. I will work at losing some weight so that my weight is at normal range for my age.
- D. I will limit my sodium intake every day and avoid eating high-sodium foods such as hot dogs.
- E. It is acceptable to eat red meat and cheese every day as I have been doing, as long as I cut down on the butter.
- F. I will schedule regular doctor appointments for physical examinations and monitoring my blood pressure.
Correct Answer: B,C,D,F
Rationale: Coronary artery disease affects the arteries that provide blood, oxygen, and nutrients to the myocardium. Modifiable risk factors include elevated serum cholesterol levels, cigarette smoking, hypertension, impaired glucose tolerance, obesity, physical inactivity, and stress. The client is instructed to stop smoking (not cut down), and the nurse should provide the client with resources to do so. The client is also instructed to maintain a normal weight and include physical activity in the daily schedule. The client needs to limit sodium intake and foods high in cholesterol, including red meat and cheese. The client must follow up with regular primary health care provider appointments for physical examinations and monitoring blood pressure.
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A mother brings her 6-month-old baby to the nurse practitioner for a routine well-baby check. Which behavior reported by the mother is concerning to the nurse?
- A. looks at self in a mirror
- B. brings things to mouth
- C. does not laugh or make squealing sounds
- D. begins to sit without support
Correct Answer: C
Rationale: Lack of laughing or squealing at 6 months suggests a developmental delay, as these are expected social behaviors. Other behaviors are age-appropriate.
The nurse has completed instructions regarding diet and fluid restriction for the client diagnosed with chronic kidney disease. The nurse determines that the client understands the information presented if the client selected which dessert from the dietary menu?
- A. Jell-O
- B. Sherbet
- C. Ice cream
- D. Angel food cake
Correct Answer: D
Rationale: For fluid-restricted diets in chronic kidney disease, clients should avoid foods liquid at room temperature like Jell-O, sherbet, and ice cream, which count as fluid intake. Angel food cake is a solid dessert, allowing more fluid intake by drinking to alleviate thirst.
The nurse is precepting a student nurse on the medical-surgical unit who is caring for a client with a T-tube. Which statement by the student nurse regarding the care of the tube indicates a need for further teaching?
- A. I should report a sudden increase in bile output.
- B. The client should be in a semi-Fowler's position to promote drainage.
- C. The drainage system should be kept below the level of the gallbladder.
- D. I will clamp the tube if the client becomes nauseated or begins to vomit.
Correct Answer: D
Rationale: Clamping the T-tube during nausea or vomiting risks pressure buildup; it should be reported instead. Other statements are correct.
When preparing the client with a spinal cord injury who is experiencing bladder spasms and reflex incontinence for discharge to home, the nurse should provide which instruction to prevent the problem?
- A. Avoid caffeine in your diet.
- B. Take your temperature every day.
- C. Limit your fluid intake to 1000 mL per 24 hours.
- D. Catheterize yourself every 2 hours as needed to prevent spasm.
Correct Answer: A
Rationale: Caffeine in the diet can contribute to bladder spasms and reflex incontinence; thus, it should be eliminated in the diet of the client with a spinal cord injury. The self-monitoring of the temperature is useful to detect infection, but it does nothing to alleviate bladder spasms. Limiting fluid intake does not prevent spasm, and it could place the client at further risk for urinary tract infection. Self-catheterization every 2 hours is too frequent and serves no useful purpose.
The nurse is planning discharge teaching for the parents of a child who sustained a head injury and who is now receiving tapering doses of dexamethasone. The nurse plans to make which statement to the parents?
- A. This medication decreases the chance of infection.
- B. This medication will be discontinued after two doses.
- C. If your child's face becomes puffy, the medication dose needs to be increased.
- D. This medication is tapered to decrease the chance of recurring swelling in the brain.
Correct Answer: D
Rationale: Dexamethasone sodium phosphate is a corticosteroid. The rebounding of cerebral edema is a side effect of dexamethasone sodium phosphate withdrawal if it is done abruptly. This medication decreases inflammation rather than infection. Facial edema is a common side effect that disappears when the medication is discontinued.