Nokea
The patient has been diagnosed with cardiovascular disease and placed on a low-fat diet. The patient asks the nurse, “How much fat should I have? I guess the less fat, the better.” Which information will the nurse include in the teaching session?
- A. Cholesterol intake needs to be less than 300 mg/day.
- B. Fats have no significance in health and the incidence of disease.
- C. All fats come from external sources so this can be easily controlled.
- D. Deficiencies occur when fat intake falls below 10% of daily nutrition.
Correct Answer: D
Rationale: The correct answer is D: Deficiencies occur when fat intake falls below 10% of daily nutrition.
Rationale:
1. Fat is essential for absorption of fat-soluble vitamins (A, D, E, K) and for maintaining healthy cell membranes.
2. Fat provides essential fatty acids (omega-3, omega-6) crucial for brain function and inflammation regulation.
3. Adequate fat intake prevents deficiencies like dry skin, poor wound healing, and hormonal imbalances.
4. A low-fat diet should still include at least 10% of daily nutrition from healthy fats for optimal health.
Summary:
A: Cholesterol intake is important but not the primary focus for a low-fat diet.
B: Fats are significant for health, and extreme low-fat diets can lead to deficiencies.
C: While some fats are from external sources, the body needs a minimum amount for proper functioning.
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The nurse learns about cultural issues involvedin the patient’s health care belief system and enables patients and families to achieve meaningful and supportive care. Which concept is the nurse demonstrating?
- A. Marginalized groups
- B. Health care disparity
- C. Transcultural nursing
- D. Culturally congruent care
Correct Answer: D
Rationale: The correct answer is D: Culturally congruent care. This concept refers to providing care that aligns with the patient's cultural beliefs and practices. By learning about cultural issues and enabling patients to receive care that is meaningful and supportive within their cultural context, the nurse is demonstrating culturally congruent care.
A: Marginalized groups - This refers to groups in society who are disadvantaged and face discrimination. While understanding cultural issues may be important when caring for marginalized groups, it is not the main concept demonstrated in this scenario.
B: Health care disparity - This refers to differences in access to healthcare and health outcomes among different populations. While cultural competence can help address healthcare disparities, it is not the concept being demonstrated here.
C: Transcultural nursing - This refers to providing care across different cultures. While related, it does not specifically address the nurse's role in understanding and enabling culturally appropriate care for individual patients and families.
A nurse practitioner assesses the patient and diagnoses Gardnerella vaginalis. What would be the most appropriate nursing action at this time?
- A. Advise the patient that this is an overgrowth of normal vaginal flora.
- B. Discuss the effect of this diagnosis on the patients fertility.
- C. Document the vaginal discharge as normal.
- D. Administer acyclovir as ordered.
Correct Answer: A
Rationale: The correct answer is A: Advise the patient that this is an overgrowth of normal vaginal flora. This is correct because Gardnerella vaginalis is a bacteria associated with bacterial vaginosis, which is an overgrowth of normal vaginal flora. By advising the patient of this, the nurse practitioner can provide education on the condition and treatment options.
B: Discussing the effect of this diagnosis on the patient's fertility is incorrect as Gardnerella vaginalis is not typically associated with fertility issues.
C: Documenting the vaginal discharge as normal is incorrect as Gardnerella vaginalis is indicative of an abnormal vaginal flora imbalance.
D: Administering acyclovir as ordered is incorrect as acyclovir is an antiviral medication used to treat herpes simplex virus infections, not bacterial vaginosis caused by Gardnerella vaginalis.
Which intrapartal assessment should be avoided when caring for a patient with HELLP syndrome?
- A. Abdominal palpation
- B. Venous sample of blood
- C. Checking deep tendon reflexes
- D. Auscultation of the heart and lungs
Correct Answer: A
Rationale: The correct answer is A: Abdominal palpation. Palpating the abdomen can potentially cause rupture of the liver in patients with HELLP syndrome due to increased risk of liver hematoma. This can lead to severe bleeding and compromise the patient's condition. Checking deep tendon reflexes (C), auscultation of the heart and lungs (D), and venous sample of blood (B) are safe assessments that do not pose a risk of exacerbating the patient's condition. It is crucial to prioritize patient safety and avoid interventions that can harm the patient, making avoiding abdominal palpation the correct choice in caring for a patient with HELLP syndrome.
A man comes to the clinic complaining that he is having difficulty obtaining an erection. When reviewing the patients history, what might the nurse note that contributes to erectile dysfunction?
- A. The patient has been treated for a UTI twice in the past year.
- B. The patient has a history of hypertension.
- C. The patient is 66 years old.
- D. The patient leads a sedentary lifestyle.
Correct Answer: B
Rationale: The correct answer is B: The patient has a history of hypertension. Hypertension is a risk factor for erectile dysfunction as it can lead to reduced blood flow to the penis, impacting the ability to achieve and maintain an erection. High blood pressure can damage blood vessels and affect the circulation necessary for an erection. Other choices are less likely to directly contribute to erectile dysfunction. A: UTI treatment is not typically associated with erectile dysfunction. C: Age alone is not a direct cause of erectile dysfunction, although it can increase the risk. D: While a sedentary lifestyle can impact overall health, it is less likely to directly cause erectile dysfunction compared to hypertension.
A patient is receiving opioids for pain. Which bowel assessment is a priority?
- A. Clostridium difficile
- B. Constipation
- C. Hemorrhoids
- D. Diarrhea
Correct Answer: B
Rationale: The correct answer is B: Constipation. When a patient is receiving opioids, constipation is a common side effect due to decreased gut motility. It is a priority assessment because untreated constipation can lead to serious complications such as bowel obstruction. Monitoring for constipation allows for early intervention with stool softeners or laxatives to prevent complications.
Incorrect choices:
A: Clostridium difficile - While important to consider in patients on antibiotics, it is not directly related to opioid use.
C: Hemorrhoids - Although opioids can contribute to constipation which may exacerbate hemorrhoids, it is not the priority assessment.
D: Diarrhea - Opioids typically cause constipation, so diarrhea is less likely to be a priority concern in this scenario.