Nokea
When assessing a client with autoimmune disorder, what signs should the nurse look for in the client?
- A. Hypotension
- B. Hives or rashes
- C. Localized inflammation
- D. Cramping and vomiting
Correct Answer: B
Rationale: The correct answer is B: Hives or rashes. In autoimmune disorders, the immune system mistakenly attacks the body's own tissues, leading to various symptoms. Hives or rashes are common manifestations of autoimmune disorders due to the immune response affecting the skin. Other choices are incorrect because hypotension is not typically associated with autoimmune disorders, localized inflammation may be present but is not specific to autoimmune disorders, and cramping and vomiting are not primary signs of autoimmune disorders.
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Which of the following is a nurse patient care role in the preoperative phase?
- A. Obtaining preoperative orders
- B. Offering emotional support
- C. Explaining the surgical procedure
- D. Providing informed consent
Correct Answer: B
Rationale: The correct answer is B: Offering emotional support. In the preoperative phase, a nurse's role includes comforting and reassuring the patient to reduce anxiety and promote emotional well-being. This is crucial for the patient's overall experience and can positively impact their recovery. Obtaining preoperative orders (A) is typically the responsibility of the physician. Explaining the surgical procedure (C) is usually done by the surgeon. Providing informed consent (D) involves ensuring the patient understands the risks and benefits of the procedure, which is typically the responsibility of the healthcare provider performing the procedure.
A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (sub-arachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist’s instructions. Why does the client require special positioning for this type of anesthesia?
- A. To prevent confusion
- B. To prevent cerebrospinal fluid (CSF)
- C. To prevent seizures leakage
- D. To prevent cardiac arrhythmias
Correct Answer: B
Rationale: The correct answer is B: To prevent cerebrospinal fluid (CSF) leakage.
Rationale: During a spinal block, the anesthesiologist injects anesthesia into the subarachnoid space, which contains CSF. Proper positioning ensures that the anesthesia stays in place and prevents leakage of CSF, which could lead to complications such as post-dural puncture headache.
Incorrect choices:
A: To prevent confusion - Irrelevant to the procedure.
C: To prevent seizures leakage - Seizures are not a concern with spinal blocks.
D: To prevent cardiac arrhythmias - Cardiac arrhythmias are not directly related to spinal blocks.
Which iron-rich foods should the nurse encourage an anemic client requiring iron therapy to eat?
- A. Shrimp and tomatoes
- B. Cheese and bananas
- C. Lobster and squash
- D. Lamb and peaches
Correct Answer: D
Rationale: The correct answer is D (Lamb and peaches) because lamb is a good source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Peaches are high in vitamin C, which enhances iron absorption. Shrimp and tomatoes (A) have some iron but are not as rich in iron as lamb. Cheese and bananas (B) are not significant sources of iron. Lobster and squash (C) also do not provide as much iron as lamb. Overall, the combination of heme iron from lamb and vitamin C from peaches makes them the most suitable choices for an anemic client requiring iron therapy.
The dietary practice that will help a client reduce the dietary intake of sodium is
- A. Increasing the use of dairy products
- B. Using an artificial sweetener in coffee
- C. Avoiding the use of carbonated beverages
- D. Using catsup for cooking and flavoring food
Correct Answer: C
Rationale: The correct answer is C: Avoiding the use of carbonated beverages. Carbonated beverages often have high sodium content, which can contribute to increased sodium intake. By avoiding these beverages, the client can significantly reduce their sodium consumption.
Explanation:
1. Carbonated beverages often contain added sodium for flavor enhancement.
2. By avoiding carbonated beverages, the client eliminates a significant source of hidden sodium in their diet.
3. This dietary practice directly targets reducing sodium intake without compromising other nutritional aspects of the diet.
Summary of other choices:
A: Increasing the use of dairy products - Dairy products do not necessarily impact sodium intake significantly.
B: Using an artificial sweetener in coffee - Artificial sweeteners do not contribute to sodium intake.
D: Using catsup for cooking and flavoring food - Catsup is high in sodium and would not help in reducing sodium intake.
Which of the following data regarding a client with a diagnosis of colon cancer are subjective?
- A. The client’s chemotherapy causes him nausea and loss of appetite.
- B. The client became teary when his daughter from out of state came to the bedside.
- C. The client’s ileostomy put out 125 mL of effluent in the past four hours.
- D. The patient is unwilling to manipulate or empty his ostomy bag.
Correct Answer: A
Rationale: The correct answer is A because subjective data refers to information reported by the client, such as their symptoms or feelings. In this case, the client experiencing nausea and loss of appetite due to chemotherapy is subjective as it is based on the client's personal experience and perception.
Choice B is incorrect because the client becoming teary is an observable behavior, making it an objective data point. Choice C is incorrect as the amount of effluent from the ileostomy is a measurable and quantifiable data, making it objective. Choice D is also incorrect as the patient's unwillingness to manipulate or empty his ostomy bag is an observable behavior, not based on the client's report.