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What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)?
- A. Sleep without pillows at night to maintain neck alignment.
- B. Adjust food intake to three full meals per day and no snacks.
- C. Minimize symptoms by wearing loose, comfortable clothing
- D. Avoid participation in any aerobic exercise programs
Correct Answer: C
Rationale: Loose clothing reduces pressure on the abdomen, which can help minimize GERD symptoms.
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Mental retardation is found in all the following:
- A. Trisomy 21
- B. Morquio syndrome
- C. Homocystinuria
- D. Ehlers-Danlos syndrome
Correct Answer: A
Rationale: Trisomy 21 (Down syndrome) is a well-known cause of mental retardation. Morquio syndrome, Homocystinuria, and Ehlers-Danlos syndrome are not typically associated with mental retardation.
A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes,. Which assessment should the nurse implement first?
- A. Evaluate distal capillary refill for delayed perfusion
- B. Check the extremities for bruising and petechiae
- C. Examine the pretibial regions for pitting edema
- D. Palpate the abdomen for tenderness and rigidity
Correct Answer: D
Rationale: Palpating the abdomen helps assess for complications such as peritonitis or worsening ascites.
What is the age-predicted maximum heart rate in a 60-year old man on beta blockers?
- A. 122
- B. 133
- C. 155
- D. 166
Correct Answer: A
Rationale: Beta blockers reduce the maximum heart rate. The age-predicted maximum heart rate for a 60-year-old on beta blockers is approximately 122 bpm.
Which is an important nursing consideration when chest tubes will be removed from a child?
- A. Explain that it is not painful.
- B. Explain that only a Band-Aid will be needed.
- C. Administer analgesics before the procedure.
- D. Expect bright red drainage for several hours after removal.
Correct Answer: C
Rationale: It is appropriate to prepare the child for the removal of chest tubes with analgesics. Short-acting medications can be used that are administered through an existing IV line. A sharp, momentary pain is felt. This should not be misrepresented to the child. A petroleum gauze, air-tight dressing will be needed, but it is not a pain-free procedure. Little or no drainage should be found on removal.
Pulmonary hypotension in a neonate associate with
- A. Diaphragmatic hernia
- B. Oxygen therapy
- C. Meconium aspiration
- D. Pneumothrax
Correct Answer: A
Rationale: Diaphragmatic hernia can lead to decreased lung expansion and pulmonary hypotension.