Nokea
What is the most suitable snack food for the LPN/LVN to offer a client with myasthenia gravis who is at risk for altered nutritional status?
- A. Chocolate pudding.
- B. Graham crackers.
- C. Sugar-free gelatin.
- D. Apple slices.
Correct Answer: A
Rationale: Chocolate pudding is the best snack food choice for a client with myasthenia gravis at risk for altered nutritional status due to its nutrient density and soft texture, which can be easier for clients with swallowing difficulties to consume. Graham crackers, sugar-free gelatin, and apple slices may not provide the same level of nutrient density or ease of consumption for these clients. Graham crackers and apple slices may also pose challenges for clients with swallowing difficulties, while sugar-free gelatin, although a good option for some clients, may not offer the same level of nutrition as chocolate pudding.
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The client is learning about lifestyle changes to manage hypertension. Which statement by the client requires further teaching?
- A. I will reduce my salt intake.
- B. I will exercise for 30 minutes most days of the week.
- C. I will drink alcohol only on the weekends.
- D. I will monitor my blood pressure regularly.
Correct Answer: C
Rationale: The correct answer is C. Clients with hypertension should ideally avoid or limit alcohol intake rather than just restricting it to weekends. Excessive alcohol consumption can raise blood pressure and interfere with the effectiveness of hypertension management. Choices A, B, and D are all positive statements that align with managing hypertension: reducing salt intake, regular exercise, and monitoring blood pressure are all beneficial lifestyle changes for individuals with hypertension. Therefore, the statement about drinking alcohol only on weekends requires further teaching to emphasize the importance of reducing alcohol consumption for better blood pressure control.
The nurse is planning care for a 12-year-old child with sickle cell disease in a vaso-occlusive crisis affecting the elbow. Which one of the following should be the priority?
- A. Limiting fluids
- B. Client-controlled analgesia
- C. Applying cold compresses to the elbow
- D. Performing passive range of motion exercises
Correct Answer: B
Rationale: During a vaso-occlusive crisis in sickle cell disease, the priority intervention is effective pain management. Client-controlled analgesia allows the child to self-administer pain relief as needed, promoting comfort and reducing stress. Limiting fluids (choice A) is not appropriate in this scenario as hydration is essential to prevent complications. Cold compresses (choice C) may provide some comfort but do not address the underlying pain. Passive range of motion exercises (choice D) are contraindicated during a vaso-occlusive crisis due to the risk of further pain and tissue damage.
A nurse is talking with caregivers of a 12-year-old child. Which of the following issues verbalized by the caregivers should the nurse identify as the priority?
- A. "We just don't understand why our child can't keep up with the other kids in simple activities like running and jumping."
- B. "Our child keeps trying to find ways around our household rules. They always want to make deals with us."
- C. "We think our child is trying too hard to excel in math just to get the top grades in the class."
- D. "Our child likes to sing and worries it will make the other kids want to laugh."
Correct Answer: A
Rationale: The correct answer is A. Difficulty in keeping up with physical activities like running and jumping may indicate an underlying physical or developmental issue that requires prompt assessment. This could be related to musculoskeletal problems, coordination difficulties, or other health concerns that need further evaluation. Choices B, C, and D, while important, do not address a potential physical or developmental issue that could impact the child's overall well-being. Addressing the child's physical limitations should be the priority to ensure appropriate support and intervention.
A healthcare professional is preparing to administer an intramuscular injection to a client. Which site is most appropriate for the healthcare professional to use?
- A. Deltoid muscle
- B. Ventrogluteal site
- C. Dorsogluteal site
- D. Rectus femoris site
Correct Answer: B
Rationale: The ventrogluteal site is the most appropriate site for administering an intramuscular injection to an adult client. This site is preferred due to its large muscle mass and distance from major nerves and blood vessels, reducing the risk of injury or complications. The deltoid muscle, while commonly used for vaccinations, may not be suitable for certain medications due to its smaller muscle mass. The dorsogluteal site is no longer recommended due to the proximity of the sciatic nerve, which can lead to complications. The rectus femoris site is not commonly used for intramuscular injections in clinical practice.
What action should be taken to maintain the patency of a peripherally inserted central catheter (PICC)?
- A. Flush the catheter with heparin solution daily.
- B. Change the dressing at the insertion site daily.
- C. Use sterile technique when changing the dressing.
- D. Keep the insertion site dry at all times.
Correct Answer: C
Rationale: The correct answer is to use sterile technique when changing the dressing. This practice is essential for preventing infections that can compromise the patency of the PICC line. While flushing the catheter with heparin solution helps prevent clot formation, it does not directly maintain patency. Changing the dressing daily is important for hygiene but does not have a direct impact on catheter patency. Keeping the insertion site dry is crucial to prevent infections but does not specifically address patency maintenance.