Nokea
The physician has ordered a low-sodium diet for a client with hypertension. Which food should the nurse instruct the client to avoid?
- A. Fresh fruit
- B. Grilled chicken
- C. Canned soup
- D. Brown rice
Correct Answer: C
Rationale: Canned soups are high in sodium, which exacerbates hypertension. Fresh fruit, grilled chicken, and brown rice are low-sodium options suitable for a hypertension diet.
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A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for the nurse to remember which of the following principles?
- A. The parts of a system are only minimally related.
- B. Dysfunction in one part affects every other part.
- C. A family system has no boundaries.
- D. Healthy families are enmeshed.
Correct Answer: B
Rationale: Any change in any part of the system affects all other parts.
The nurse is caring for a client with a diagnosis of oligohydramnios. Which finding is most likely to be present?
- A. Decreased fetal movement
- B. Increased fetal heart rate
- C. Uterine size larger than expected
- D. Fetal macrosomia
Correct Answer: A
Rationale: Oligohydramnios (low amniotic fluid) can restrict fetal movement due to limited space making decreased fetal movement a likely finding. Fetal heart rate may be normal or show distress uterine size is smaller and macrosomia is unrelated.
The nurse is caring for a client with a history of congestive heart failure. The nurse should give priority to:
- A. Monitoring for arrhythmias
- B. Administering bronchodilators
- C. Monitoring for hyperglycemia
- D. Assessing for skin breakdown
Correct Answer: A
Rationale: Congestive heart failure increases the risk of arrhythmias due to cardiac strain, making monitoring for arrhythmias a priority to prevent sudden cardiac events.
A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, 'Why did this happen to my baby?' is:
- A. It's God's will. It was probably for the best. There was something probably wrong with your baby.'
- B. You're young. You can have other children later.'
- C. I know your other children will be a great comfort to you.'
- D. I can see you're upset. Would you like to see and hold your baby?'
Correct Answer: D
Rationale: The mother and the father require Wsupport; the nurse should not minimize their grief in this situation. Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child. Attachment to this infant occurs during the pregnancy for both the mother and father. Siblings will not replace their feelings or minimize their loss of this infant. Holding and viewing the infant decreases denial and may facilitate the grief process. The nurse should prepare family members for how the infant appears ('she is bruised') and provide support.
A client arrives in the emergency room with severe burns of the hands, right arm, face, and neck. The nurse needs to start an IV.
- A. Top of client's right hand
- B. Left antecubital fossa
- C. Top of either foot
- D. Left forearm
Correct Answer: B
Rationale: The left antecubital fossa is suitable for IV placement, avoiding burned areas (right hand, arm, face, neck). The foot (C) is less ideal due to infection risk, and the left forearm (D) may be too close to burn sites.