Nokea
When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?
- A. Bread
- B. Oranges
- C. Carrots
- D. Strawberries
Correct Answer: D
Rationale: The correct answer is D: Strawberries. Strawberries are a common allergen due to their high allergenic potential. When taking a dietary history, it is important to identify potential allergens to prevent adverse reactions. Oranges, carrots, and bread are not as commonly associated with allergies compared to strawberries. Identifying common allergens helps in providing safe and appropriate dietary recommendations for clients.
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During chemotherapy, an oncology client has a nursing diagnosis of impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?
- A. Recommending that the client discontinue chemotherapy
- B. Providing a solution of hydrogen peroxide and water for use as a mouth rinse
- C. monitoring the client’s platelet and leukocyte counts
- D. Checking regularly for signs and symptoms of stomatitis
Correct Answer: B
Rationale: Step 1: Providing a solution of hydrogen peroxide and water as a mouth rinse helps in reducing the pain of stomatitis by promoting oral hygiene and preventing infections.
Step 2: Hydrogen peroxide has antimicrobial properties that can help in reducing bacteria in the mouth, which can worsen stomatitis.
Step 3: Rinsing with this solution can also help in cleansing the oral mucosa and reducing inflammation, thereby decreasing pain.
Step 4: This intervention directly addresses the nursing diagnosis of impaired oral mucous membrane and is focused on symptom management.
Summary:
A: Recommending the client to discontinue chemotherapy is not a feasible option as it is essential for treating cancer.
C: Monitoring platelet and leukocyte counts is important but does not directly address the pain of stomatitis.
D: Checking for signs and symptoms is necessary but does not provide direct relief for the pain of stomatitis.
The nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority?
- A. Disturbed body image related to changes in body functions
- B. Ineffective airway clearance related to obstruction by a tumor or secretions
- C. Anxiety related to actual threat to health status and changes in family dynamics
- D. Imbalanced nutrition: Less than body requirements related to anorexia and vomiting secondary to chemotherapy
Correct Answer: B
Rationale: The correct answer is B: Ineffective airway clearance related to obstruction by a tumor or secretions. This takes highest priority as compromised airway can lead to respiratory distress and potential respiratory failure. Maintaining clear airways is essential for oxygenation and ventilation. Choices A, C, and D are important but do not pose immediate life-threatening risks compared to compromised airway. Disturbed body image, anxiety, and imbalanced nutrition can be addressed once the airway clearance is stabilized.
The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling and induration at the wound site. What do these signs suggest?
- A. Infection
- B. Evisceration
- C. Dehiscence
- D. Hemorrhage
Correct Answer: A
Rationale: The presence of redness, swelling, and induration at the wound site are indicative of infection. Redness and swelling suggest inflammation, while induration indicates tissue hardening and can be a sign of infection spreading. Infection can delay healing and lead to complications if not treated promptly. Evisceration refers to wound opening with protrusion of internal organs, not indicated by the symptoms. Dehiscence is the partial or complete separation of wound layers, not represented by the symptoms. Hemorrhage involves excessive bleeding, which is not described in the scenario. Therefore, choice A is correct as it aligns with the signs observed and is the most appropriate response for the situation.
Which food choice contains the highest kilocalorie?
- A. Apple
- B. Chicken
- C. Bacon
- D. Bread
Correct Answer: C
Rationale: The correct answer is C: Bacon. Bacon contains the highest kilocalorie among the given choices due to its high fat content. Fat provides 9 kilocalories per gram, while carbohydrates (like in bread and apple) provide 4 kilocalories per gram and protein (like in chicken) provides 4 kilocalories per gram. Bacon, being high in fat, has more kilocalories compared to the other choices.
Summary:
A: Apple - Low in fat, primarily consists of carbohydrates, hence lower in kilocalories.
B: Chicken - Contains protein, lower in kilocalories compared to fat, hence not the highest kilocalorie choice.
D: Bread - Mainly consists of carbohydrates, lower in kilocalories compared to fat, making it not the highest kilocalorie choice.
A 17-year-old boy is admitted in sickle cell crisis. Which of the ff. events most likely contributed to the onset of the crisis?
- A. He started a new job last week.
- B. He had seafood for dinner last night.
- C. He walked home in a cold rain
- D. He has not exercised for a week. yesterday.
Correct Answer: C
Rationale: The correct answer is C: He walked home in a cold rain. Walking in cold rain can lead to vasoconstriction, which impairs blood flow, increasing the likelihood of a sickle cell crisis in individuals with sickle cell disease. This can cause red blood cells to sickle and block blood vessels, leading to pain and tissue damage. Choices A, B, and D do not directly affect the physiology of sickle cell disease and are less likely to trigger a crisis.