Nokea
The nurse who is caring for a client with cancer notes a WBC of 500/mm3 on the laboratory results. Which intervention would be most appropriate to include in the client's plan of care?
- A. Assess temperature every four hours because of risk for hypothermia.
- B. Instruct the client to avoid large crowds and people who are sick.
- C. Instruct in the use of a soft toothbrush.
- D. Assess for signs of bleeding.
Correct Answer: B
Rationale: A WBC of 500/mm3 indicates severe neutropenia, increasing infection risk. Avoiding crowds and sick people (B) is critical. Hypothermia (A) is not a primary concern, soft toothbrush (C) prevents bleeding, and bleeding (D) is for thrombocytopenia.
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The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks' gestation. An appropriate response by the nurse would be:
- A. It must be God's will and probably is for the best.'
- B. This must be a difficult time for you. Would you like to talk about it?'
- C. I'm sure your other children will be a comfort for you.'
- D. Don't worry, you're still young. If I were you I'd just try again.'
Correct Answer: B
Rationale: This response is nontherapeutic because it belittles the client's response and gives a meaningless rationalization. This response acknowledges the client's feelings and demonstrates the therapeutic offering of self by the nurse. This response is nontherapeutic because it does not focus on the client's feelings and offers false reassurance. This response is nontherapeutic because it belittles the client's feelings and offers her advice.
The home care nurse is preparing a teaching plan for a client with deficiencies in folic acid. Which foods will increase the clients' folic acid level?
- A. Broccoli
- B. Cabbage
- C. Chicken
- D. Dried fruit
- E. White bread
- F. Milk
Correct Answer: A, B, D
Rationale: Folic acid-rich foods include broccoli (A), cabbage (B), and dried fruit (D). Chicken (C), white bread (E), and milk (F) are low in folate.
A client has a history of alcoholism. He is currently diagnosed with cirrhosis of the liver. The nurse would expect him to be on which type of diet?
- A. High protein and high calorie
- B. High calorie and high carbohydrate
- C. Low-fat 2-g sodium diet
- D. High protein and high fat
Correct Answer: B
Rationale: High carbohydrates provide high-caloric content to prevent tissue catabolism.
Which measure helps reduce nipple soreness associated with breastfeeding?
- A. Feeding the baby during the first 48 hours after delivery
- B. Placing a finger between the baby's mouth and the breast to break suction after feeding
- C. Applying warm, moist soaks to the breast several times per day
- D. Wearing a support bra during the day
Correct Answer: B
Rationale: Breaking suction by placing a finger between the baby’s mouth and the breast prevents trauma to the nipple, reducing soreness. Feeding early promotes latch but doesn’t address soreness directly, warm soaks may increase inflammation, and a bra supports but doesn’t prevent nipple trauma.
A client with AIDS has impaired nutrition due to diarrhea. The nurse teaches the client about the need to avoid certain foods.
- A. Tossed salad
- B. Baked chicken
- C. Broiled fish
- D. Steamed rice
Correct Answer: A
Rationale: Raw foods like tossed salad (A) can harbor pathogens, risky for AIDS patients with diarrhea. Baked chicken (B), broiled fish (C), and steamed rice (D) are cooked and safer, indicating further teaching is needed for A.