Nokea
When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend?
- A. Biofeedback
- B. Deep breathing
- C. Distraction
- D. Imagery
Correct Answer: B
Rationale: Deep breathing. Deep breathing is a reliable and valid method for reducing stress, and can be taught and reinforced in a short period pre-operatively.
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The nurse has been teaching a client with congestive heart failure about proper nutrition. Which of these lunch selections indicates the client has learned about sodium restriction?
- A. Cheese sandwich with a glass of 2% milk
- B. Sliced turkey sandwich and canned pineapple
- C. Cheeseburger and baked potato
- D. Mushroom pizza and ice cream
Correct Answer: B
Rationale: Sliced turkey sandwich and canned pineapple. Sliced turkey sandwich is appropriate since it is not a highly processed food and canned fruits are low in sodium. All of the other choices contain one or more high-sodium foods.
The client on Floxin must be alerted to which of the following adverse effects?
- A. stunting of height in teens and young adults
- B. propensity of anovulatory uterine bleeding
- C. intractable diarrhea
- D. tendon rupture
Correct Answer: D
Rationale: Floxin is a quinolone antibiotic used in respiratory infections and pelvic and reproductive infections. Rarely, quinolones can cause tendon sheath rupture, usually of the Achilles. At the first indication of tendon pain, the antibiotic should be discontinued.
A client with a history of a splenectomy has a left upper quadrant mass and is scheduled for a splenectomy. The nurse knows that this client is most at risk for what complication?
- A. Respiratory complications
- B. Bleeding tendencies
- C. Peritonitis
- D. Intestinal obstruction
Correct Answer: B
Rationale: The spleen plays a role in filtering blood and producing immune cells. A history of splenectomy increases the risk of bleeding due to decreased platelet function and impaired immune response.
When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because
- A. normal patterns of behavior may be labeled as deviant, immoral, or insane
- B. the meaning of the client's behavior can be derived from conventional wisdom
- C. personal values will guide the interaction between persons from 2 cultures
- D. the nurse should rely on her knowledge of different developmental mental stages
Correct Answer: A
Rationale: Normal patterns of behavior may be labeled as deviant, immoral, or insane. Culture is an important variable in the assessment of individuals. To work effectively with clients, the nurse must be aware of a cultural distinctive qualities.
Padding on a restraint helps:
- A. with pressure distribution so that bony prominences do not receive pressure when a client pulls against the restraints.
- B. the client feel more secure.
- C. to keep infection and wounds down.
- D. to keep restraints in place.
Correct Answer: A
Rationale: Padding distributes pressure so that bony prominences do not receive the brunt of pressure when a client pulls against the restraints. Pressure, especially over bony prominences, causes tissue damage due to ischemia.