Nokea
What dietary advice should the nurse give to clients with HIV/AIDS?
- A. Encourage the intake of fat soluble vitamins in amounts 2 to 5 times the recommended daily allowance (RDA)
- B. Encourage intake of water soluble vitamins in amounts 2 to 5 times the RDA
- C. Increase the intake of iron and zinc
- D. Decrease the intake of trace elements and antioxidant supplements
Correct Answer: D
Rationale: The correct answer is D: Decrease the intake of trace elements and antioxidant supplements. Clients with HIV/AIDS do not require additional trace elements and antioxidant supplements, as excessive intake can be harmful. HIV/AIDS already places stress on the immune system, so taking excessive supplements may lead to toxicity. It is important to focus on a balanced diet rich in essential nutrients rather than overloading the body with unnecessary supplements. Encouraging a healthy, balanced diet will help support overall health and immune function in clients with HIV/AIDS.
Choices A, B, and C are incorrect because encouraging excessive intake of fat-soluble vitamins, water-soluble vitamins, iron, and zinc can also lead to potential adverse effects. It is important to focus on meeting the recommended daily allowances for these nutrients rather than exceeding them.
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According to Maslow’s hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?
- A. Ineffective airway clearance
- B. Ineffective coping
- C. Impaired urinary elimination
- D. Risk for body image disturbance
Correct Answer: D
Rationale: The correct answer is D: Risk for body image disturbance. In the context of Maslow's hierarchy of needs, physiological needs take precedence over psychological needs. For a client in the intensive care unit with congestive heart failure, ensuring physiological needs like airway clearance, urinary elimination, and coping are addressed first is crucial for survival. Body image disturbance is a higher-level psychological need and can be addressed once basic physiological needs are met. Therefore, addressing the risk for body image disturbance would have the lowest priority compared to the other options provided.
One of the dangers of treating hypernatremia is:
- A. Red blood cell crenation
- B. Cerebral edema
- C. Red blood cell hydrolysis
- D. Renal shutdown
Correct Answer: B
Rationale: The correct answer is B: Cerebral edema. Hypernatremia is an elevated sodium level in the blood, which can lead to osmotic shifts causing water to move out of cells, including brain cells. This can result in cerebral edema, potentially leading to neurological complications.
Incorrect choices:
A: Red blood cell crenation - This occurs in hypertonic solutions, not hypernatremia.
C: Red blood cell hydrolysis - Hypernatremia doesn't directly cause red blood cell hydrolysis.
D: Renal shutdown - Hypernatremia can stress the kidneys, but it doesn't typically lead to renal shutdown.
A client who suffered a vehicular accident a few days ago is in skeletal traction. Which nursing action would BESt promote INDEPENDENCE for this patient?
- A. tell the client to call for an analgesic before the pain felt becomes severe
- B. encourage the patient to do leg exercises within the limits of his traction
- C. provide an overhead trapeze for client use on the Balkan frame
- D. provide skin care to prevent skin breakdown
Correct Answer: B
Rationale: The correct answer is B because encouraging the patient to do leg exercises within the limits of his traction promotes independence by maintaining muscle strength and mobility. This helps prevent muscle atrophy and promotes circulation. Choice A focuses on pain management but does not directly promote independence. Choice C provides assistance but does not actively involve the patient in self-care. Choice D is important for overall care but does not directly promote independence through active patient involvement.
A nurse evaluates a client’s response to a nursing intervention and determines that the expected outcome was not achieved. What is the nurse’s most appropriate action?
- A. Terminate the plan of care
- B. Modify the plan of care
- C. Reassign care to another nurse
- D. Reassess the client’s condition
Correct Answer: D
Rationale: The correct answer is D: Reassess the client's condition. When an expected outcome is not achieved, the nurse must reassess the client's condition to identify the reasons for the lack of success. This step allows the nurse to gather more information, adjust the plan of care if necessary, and determine the most suitable course of action to help the client achieve the desired outcome.
Choice A: Terminating the plan of care is premature without reassessing the client's condition and identifying potential barriers to success.
Choice B: Modifying the plan of care may be necessary after reassessment but should not be the first step.
Choice C: Reassigning care to another nurse does not address the underlying issues affecting the client's response to the intervention.
The nurse understands that a patient with BP readings 164/102 and 176/100 on two separate occasions would be classified in which hypertension category?
- A. Prehypertension
- B. Stage 2
- C. Stage 1
- D. Posthypertension
Correct Answer: B
Rationale: The correct answer is B: Stage 2 hypertension. The patient's BP readings consistently fall within the range of 160-179 systolic or 100-109 diastolic, which aligns with the criteria for Stage 2 hypertension based on the current guidelines. This classification indicates a higher level of hypertension that requires prompt medical attention and intervention to reduce the risk of complications. Choices A, C, and D are incorrect because they do not correspond to the BP readings provided, falling outside the range for prehypertension, Stage 1 hypertension, and posthypertension.