Nokea
When caring for a client at the end of life, which statement by the client's partner reflects effective coping?
- A. I am relying on support from our family during this time.
- B. I am feeling overwhelmed but don't want to talk about it.
- C. I am managing everything on my own without help.
- D. I prefer to stay alone with my partner.
Correct Answer: A
Rationale: The correct answer is A: 'I am relying on support from our family during this time.' When a client is at the end of life, relying on support from family can be an effective coping mechanism. It allows the partner to share the emotional burden, seek comfort, and prevent feelings of isolation. Choice B reflects a reluctance to express feelings, which can hinder coping mechanisms by internalizing stress. Choice C suggests handling everything alone, which can lead to burnout and emotional strain due to the overwhelming responsibilities. Choice D, preferring to stay alone with the partner, may limit access to external support that could provide additional emotional and practical assistance during this challenging time, making it a less effective coping strategy.
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During an assessment, a client receiving tube feedings via NG tube shows signs of nasal mucosa irritation. What finding should the nurse report to the provider?
- A. Potassium 5.5 mEq/L
- B. Irritation of nasal mucosa
- C. Sodium 144 mEq/L
- D. Loose stools
Correct Answer: B
Rationale: Irritation of nasal mucosa is a crucial finding that the nurse should report to the provider as it suggests potential complications with NG tube placement, such as improper positioning or mucosal damage. High potassium levels (Choice A) can be concerning but are not directly related to NG tube placement issues. Normal sodium levels (Choice C) and loose stools (Choice D) are common occurrences in clients receiving tube feedings and are not typically indicative of immediate complications that require urgent reporting.
During assessment, what is a nurse monitoring when assessing body alignment?
- A. The relationship of one body part to another in different positions
- B. The coordination between musculoskeletal and nervous systems
- C. The force opposing movement direction
- D. The ability to move freely
Correct Answer: A
Rationale: When a nurse assesses body alignment, they are observing the relationship of one body part to another in various positions. This involves evaluating the positioning of joints, tendons, ligaments, and muscles while a person is standing, sitting, or lying down. Choice B is incorrect because it refers more to the coordination between the musculoskeletal and nervous systems, which is not specifically related to body alignment assessment. Choice C is incorrect as it describes the force opposing movement rather than body alignment. Choice D is incorrect as it defines the ability to move freely, which is not directly related to monitoring body alignment.
A client has a sodium level of 125. What findings should the nurse expect?
- A. Abdominal cramping
- B. Elevated blood pressure
- C. Decreased heart rate
- D. Increased thirst
Correct Answer: A
Rationale: Low sodium levels (hyponatremia) often present with various symptoms, including abdominal cramping. Abdominal cramping is a common manifestation of hyponatremia due to the altered electrolyte balance. Option B ('Elevated blood pressure') is incorrect because low sodium levels typically lead to decreased blood pressure, not elevated. Option C ('Decreased heart rate') is incorrect as low sodium levels are more likely to cause an irregular heart rate rather than a decreased heart rate. Option D ('Increased thirst') is incorrect because excessive thirst is more commonly associated with high sodium levels (hypernatremia) rather than low sodium levels.
A healthcare professional is planning care to improve self-feeding for a client with vision loss. Which of the following interventions should the healthcare professional include in the plan of care?
- A. Instruct the client on the sequence of foods to eat first
- B. Offer small-handle utensils for the client to use
- C. Thicken liquids served to the client
- D. Use a clock pattern to indicate food placement on the client's plate
Correct Answer: D
Rationale: The correct answer is D. When a client has vision loss, using a clock pattern to describe food placement on the plate can facilitate independent eating. This method enables the client to locate different food items based on their positions, enhancing self-feeding abilities. Instructing the client on the sequence of foods to eat first (Choice A) may not address the visual impairment directly. Providing small-handle utensils (Choice B) can be helpful for clients with limited dexterity but may not specifically assist a client with vision loss. Thickening liquids (Choice C) is more relevant for clients with dysphagia, not vision loss.
The healthcare provider is educating a client about dietary changes to prevent the recurrence of calcium oxalate kidney stones. Which food should the provider advise the client to avoid?
- A. Spinach
- B. Bananas
- C. Chicken
- D. Rice
Correct Answer: A
Rationale: The correct answer is A: Spinach. Spinach is high in oxalate, a compound that can contribute to the formation of calcium oxalate kidney stones. Therefore, advising the client to avoid spinach is crucial in reducing the risk of stone recurrence. Bananas (choice B) are not high in oxalate and do not directly contribute to the formation of calcium oxalate stones, so they do not need to be avoided. Similarly, choices C and D, chicken, and rice, are not typically associated with high oxalate content, making them safe choices and do not need to be avoided specifically to prevent calcium oxalate kidney stones.