Nokea
A client is admitted with irritable bowel syndrome.
The nurse would anticipate the client's history to reflect which of the following?
- A. Pattern of alternating diarrhea and constipation.
- B. Chronic diarrhea stools occurring 10-12 times per day.
- C. Diarrhea and vomiting with severe abdominal distention.
- D. Bloody stools with increased cramping after eating.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-condition is often called spastic bowel disease; no inflammation is present (2) refers to inflammatory bowel disease such as ulcerative colitis or Crohn's disease (3) refers to inflammatory bowel disease such as ulcerative colitis or Crohn's disease (4) bloody stools do not occur
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The family of a 48-year-old woman who has multiple sclerosis and spends most of her time in bed or in a chair asks the nurse why they have been told they should have her take deep breaths and cough frequently. What should the nurse include in the reply?
- A. Deep breathing and coughing will help her to move her secretions so she will not develop pneumonia.
- B. Deep breathing and coughing help to prevent clots from developing in the lung.
- C. When she coughs, she increases the amount of oxygen going to the brain, preventing confusion.
- D. Deep breathing increases blood flow to the brain and helps to keep her from getting depressed.
Correct Answer: A
Rationale: Immobility in multiple sclerosis increases pneumonia risk; deep breathing and coughing mobilize secretions, preventing respiratory infections.
While teaching the client about the importance of prenatal vitamins.
The nurse should tell the client to take the vitamins
- A. with orange juice at bedtime.
- B. at breakfast with coffee.
- C. with milk at lunch.
- D. with water at dinner.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-taking the vitamins with something acidic increases the absorption of iron, taking them with food at bedtime decreases the possibility of nausea, as the client will be asleep (2) not the best way to take prenatal vitamins (3) not the best way to take prenatal vitamins (4) not the best way to take prenatal vitamins
A male client is preparing for discharge following an acute myocardial infarction. He asks the nurse about his sexual activity once he is home. What would be the nurse's initial response?
- A. Give him written material from the American Heart Association about sexual activity with heart disease
- B. Answer his questions accurately in a private environment
- C. Schedule a private, uninterrupted teaching session with both the client and his wife
- D. Assess the client's knowledge about his health problems
Correct Answer: D
Rationale: The nursing process is continuous and cyclical in nature. When a client expresses a specific concern, the nurse performs a focused assessment to gather additional data prior to planning and implementing nursing interventions.
A client's blood gasses are as follows: pH=7.32, pCO2=62, HCO3=30, and pO2=62. The best interpretation is that the client has which of the following?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: A
Rationale: Low pH and high pCO2 indicate respiratory acidosis, likely from CO2 retention, with HCO3 compensating.
The physician has ordered a low-magnesium diet for a client with end-stage renal failure. Which of the following diet selections should be removed from the client's meal tray?
- A. Fruit compote
- B. Spinach salad
- C. Baked potato
- D. Custard
Correct Answer: B
Rationale: Spinach is high in magnesium, which should be restricted in end-stage renal failure due to impaired excretion. Fruit compote , baked potato , and custard are lower in magnesium.