Nokea
What dietary considerations must the nurse keep in mind for a patient who is an Orthodox Jew?
- A. They can eat any food unless it is Yom Kippur
- B. They cannot mix meat and dairy
- C. They cannot eat meat on Ash Wednesday
- D. They are vegetarian
Correct Answer: B
Rationale: Orthodox Jews follow dietary laws (Kashrut) that prohibit mixing meat and dairy products in the same meal. This restriction is known as 'not mixing milk and meat.' Therefore, choice B is the correct answer. Choices A, C, and D are incorrect because being an Orthodox Jew does not mean they can eat any food unless it is Yom Kippur, avoid meat on Ash Wednesday, or are necessarily vegetarian.
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In obtaining an orthostatic vital sign measurement, what action should the nurse take first?
- A. Count the client's radial pulse
- B. Apply a blood pressure cuff
- C. Instruct the client to lie supine
- D. Assist the client to stand upright
Correct Answer: C
Rationale: The correct first action when obtaining an orthostatic vital sign measurement is to instruct the client to lie supine. This allows for establishing a baseline measurement of vital signs before any positional changes. Counting the client's radial pulse (Choice A) is a step that follows after the initial supine position to assess changes in pulse rate. Applying a blood pressure cuff (Choice B) and assisting the client to stand upright (Choice D) are actions that come later in the process after the baseline measurements are obtained in the supine position.
The nurse and unlicensed assistive personnel (UAP) are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the nurse implement?
- A. Demonstrate to the UAP how to approach the client from the client's left side
- B. Ask the UAP to leave the room and assess the client's body for bruising
- C. Carefully observe the interaction between the client and family members
- D. Instruct the UAP to protect the client's left side when transferring to a chair
Correct Answer: A
Rationale: The correct action for the nurse to implement is to demonstrate to the UAP how to approach the client from the client's left side. Approaching the client from the neglected side (left side) can help in retraining the brain and improving awareness of the affected side, which is crucial in the management of neglect syndrome. Choice B is incorrect as assessing the client's body for bruising is not directly related to managing neglect syndrome. Choice C is incorrect as observing the interaction between the client and family members does not address the specific intervention needed for neglect syndrome. Choice D is incorrect because protecting the client's left side when transferring to a chair does not actively involve retraining the brain and improving awareness of the neglected side, which is the primary goal in managing neglect syndrome.
At one minute after birth, an infant is crying, has a heart rate of 140, has acrocyanosis, resists the suction catheter, and keeps his arms extended and his legs flexed. What is the Apgar score?
- A. 4
- B. 6
- C. 8
- D. 10
Correct Answer: C
Rationale: The Apgar score is based on five components: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the infant has a heart rate over 100 (2 points), is crying (2 points indicating good respiratory effort), resists the catheter (2 points for good reflex irritability), but has acrocyanosis (partial point deduction of 1). Thus, the Apgar score at one minute after birth would be 8. Choice A is incorrect as the given signs indicate a higher score. Choice B is incorrect as the signs described support a score above 6. Choice D is incorrect as it represents a perfect score which is not the case here due to acrocyanosis.
At what age does a 9-year-old child typically lose which of the following teeth?
- A. Central incisor
- B. Second molar
- C. Lateral incisor
- D. Cuspid
Correct Answer: A
Rationale: A 9-year-old child typically loses their central incisors, not the lateral incisors or second molars. The central incisors are usually among the first teeth that children lose around 6 to 7 years of age, as part of the natural process of shedding primary teeth to make way for permanent teeth. The second molars and cuspids are typically lost later in the mixed dentition phase. Therefore, option A, 'Central incisor,' is the correct answer.
When caring for a patient with a chest tube, which nursing action is most important?
- A. Clamping the chest tube every 2 hours to prevent air leaks
- B. Keeping the drainage system below chest level
- C. Emptying the drainage system every hour to prevent backflow
- D. Removing the chest tube when drainage decreases significantly
Correct Answer: B
Rationale: The most crucial nursing action when caring for a patient with a chest tube is to keep the drainage system below chest level (choice B). This position helps ensure proper drainage and prevents backflow of fluid or air into the pleural space, promoting optimal functioning of the chest tube. Clamping the chest tube every 2 hours (choice A) is incorrect as it can obstruct the drainage system and lead to complications. Emptying the drainage system every hour (choice C) is unnecessary unless there are specific clinical indications. Removing the chest tube when drainage decreases significantly (choice D) is also incorrect as the decision should be based on overall clinical assessment rather than drainage amount alone.