Nokea
When caring for a client with a spinal cord injury, the nurse continually monitors this client for which medical emergency?
- A. Hemorrhage
- B. Hypovolemic shock
- C. Gastrointestinal atony
- D. Autonomic hyperreflexia
Correct Answer: D
Rationale: Autonomic hyperreflexia (D) is a medical emergency in spinal cord injury (SCI) above T6, causing severe hypertension from unopposed sympathetic response. Hemorrhage (A) or shock (B) requires trauma context. GI atony (C) is chronic, not emergent. D is correct. Rationale: Hyperreflexia, triggered by stimuli like bladder distension, can lead to stroke or death if untreated, requiring urgent monitoring and intervention, per SCI emergency protocols, unlike less acute complications.
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A client has a new prescription for a low-fat diet. Which of the following foods should be recommended?
- A. Bacon
- B. Whole milk
- C. Chicken breast
- D. Cheese
Correct Answer: C
Rationale: When following a low-fat diet, it is essential to choose foods that are low in fat. Chicken breast is a lean protein source that is low in fat, making it a suitable option for a low-fat diet. Bacon, whole milk, and cheese are higher in fat content and should be avoided or limited in a low-fat diet. Bacon is high in saturated fat, whole milk contains significant amounts of fat, including saturated fat, and cheese is also high in fat. Therefore, these options are not ideal for a low-fat diet.
The nurse avoided a romantic tie with Mr. Gary. This is an example of?
- A. Professional boundaries
- B. Cultural sensitivity
- C. Justice
- D. Fidelity
Correct Answer: A
Rationale: Avoiding romance is professional boundaries (A) keeping limits, per ethics. Sensitivity (B) culture, justice (C) fairness, fidelity (D) promises not boundary-specific. A fits the nurse's ethical distance, ensuring professionalism, making it correct.
A client with cirrhosis is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of sodium-rich foods.
- B. I should decrease my intake of sodium-rich foods.
- C. I should increase my intake of potassium-rich foods.
- D. I should decrease my intake of potassium-rich foods.
Correct Answer: B
Rationale: The correct answer is B. In cirrhosis, decreasing the intake of sodium-rich foods is essential to manage fluid retention and symptoms. Excessive sodium intake can worsen fluid accumulation and lead to complications such as ascites. Therefore, advising the client to decrease sodium-rich foods demonstrates an understanding of the dietary management necessary for cirrhosis. Choices A, C, and D are incorrect because increasing sodium-rich foods can exacerbate fluid retention and complications in cirrhosis, increasing potassium-rich foods is not the primary focus of dietary management in cirrhosis, and decreasing potassium-rich foods is not a key recommendation for managing cirrhosis-related dietary issues.
Which of the following nursing intervention would least likely be effective when dealing with a client with aggressive behavior?
- A. Approach him in a calm manner
- B. Provide opportunities to express feelings
- C. Maintain eye contact with the client
- D. Isolate the client from others
Correct Answer: C
Rationale: Maintaining eye contact (C) is least effective with aggressive clients; it can escalate tension, per de-escalation guidelines. Calm approach (A), expression (B), and isolation (D) soothe or manage behavior. Eye contact may provoke, making C incorrect.
The physician has prescribed Cognex (tacrine) for a client with dementia. The nurse should monitor the client for adverse reactions, which include:
- A. Increased appetite
- B. Elevated liver enzymes
- C. Hypotension
- D. Improved short-term memory
Correct Answer: B
Rationale: Elevated liver enzymes are a key adverse reaction to Cognex, requiring monitoring in dementia appetite, BP, and memory aren't primary concerns. Nurses check LFTs, ensuring safety, critical for managing Alzheimer's medication risks.