Nokea
The physician has ordered a low-potassium diet for a client with acute glomerulonephritis. Which snack is suitable for the client with potassium restrictions?
- A. Raisins
- B. Oranges
- C. Apricots
- D. Bananas
Correct Answer: A
Rationale: Raisins are lower in potassium compared to oranges, apricots, and bananas, making them suitable for a low-potassium diet.
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A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client's cervix is 8 cm dilated, with complete effacement. The priority nursing diagnosis at this time is:
- A. Alteration in coping related to pain
- B. Potential for injury related to precipitate delivery
- C. Alteration in elimination related to anesthesia
- D. Potential for fluid volume deficit related to NPO status
Correct Answer: B
Rationale: At 8 cm dilation with complete effacement, the client is in advanced labor, and the risk of precipitate delivery is high, posing a potential for injury.
The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:
- A. Within 72 hours of delivery
- B. Within 1 week of delivery
- C. Within 2 weeks of delivery
- D. Within 1 month of delivery
Correct Answer: A
Rationale: RhoGam must be administered within 72 hours postpartum to prevent Rh sensitization.
Which finding is associated with Tay Sachs disease?
- A. Pallor of the conjunctiva
- B. Cherry-red spots on the macula
- C. Blue-tinged sclera
- D. White flecks in the iris
Correct Answer: B
Rationale: Cherry-red spots on the macula are a classic finding in Tay-Sachs disease due to lipid accumulation in retinal ganglion cells.
A pregnant woman has experienced repeated vaginal monilial infections. When educating the client about the infection, which information should the nurse include? Select all that apply.
- A. Advise client to bathe daily.
- B. Explain the effects of increased estrogen production.
- C. Advise client to wear cotton panties and avoid nylon or pantyhose.
- D. Suggest client use panty liners to protect clothing.
- E. Advise the client to avoid wearing any panties.
Correct Answer: A,B,C
Rationale: Daily bathing (A), understanding estrogen's role in yeast growth (B), and wearing cotton panties (C) help manage monilial infections. Panty liners (D) may trap moisture, and avoiding panties (E) is impractical.
A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder?
- A. I keep having recurring nightmares.
- B. I have a headache and my vision is blurry.
- C. I feel like I'm watching myself from outside my body.
- D. I hear voices telling me what to do.
Correct Answer: C
Rationale: Dissociative disorders involve a disruption in the normal integration of consciousness, memory, identity, or perception. The statement 'I feel like I'm watching myself from outside my body' is indicative of depersonalization, a common symptom of dissociative disorders. Option A is associated with PTSD, B suggests a physical issue, and D is characteristic of psychotic disorders.