Nokea
Which BMI is typically associated with anorexia nervosa?
- A. Increase protein intake
- B. Reduce carbohydrate consumption
- C. Drink more water
- D. Take vitamin supplements
Correct Answer: C
Rationale: The correct answer is C because it is the most appropriate response based on physiological and medical principles.
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A healthcare worker is caring for a group of clients in an infectious disease unit. The worker should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases?
- A. Pertussis
- B. Mycoplasma pneumonia
- C. Tuberculosis
- D. Respiratory syncytial virus
Correct Answer: C
Rationale: The correct answer is C: Tuberculosis. Healthcare workers should wear an N95 respirator mask when caring for clients with airborne infectious diseases like tuberculosis. The N95 mask is designed to filter out at least 95% of airborne particles, including those that may carry the tuberculosis bacteria. This level of protection is necessary to prevent the healthcare worker from inhaling the infectious agent.
Pertussis (A), Mycoplasma pneumonia (B), and Respiratory syncytial virus (D) are not typically transmitted through the air and therefore do not require the use of an N95 respirator mask for standard care. These diseases are usually spread through respiratory droplets or direct contact, so standard precautions such as wearing a surgical mask and gloves are sufficient.
What observation would indicate the water-seal drainage system is working correctly?
- A. No bubbling of air in the suction control bottle
- B. Fluctuation of the fluid level in the tube of the water-seal bottle
- C. 25 ml of serosanguineous fluid has collected in the drainage bottle
- D. Excessive bubbling in the water-seal bottle
Correct Answer: B
Rationale: Fluctuation indicates proper lung expansion and absence of leaks.
A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?
- A. Prevent aspiration.
- B. Ensure adequate nutrition.
- C. Promote oral hygiene.
- D. Relieve the client's pain.
Correct Answer: A
Rationale: The correct answer is A: Prevent aspiration. This is the priority because with intermaxillary fixation, the client is unable to open their mouth, increasing the risk of aspiration. Aspiration can lead to serious complications, such as pneumonia. Ensuring the client's airway is clear and they are able to breathe properly should be the top priority.
Summary:
- B: Ensuring adequate nutrition can be important, but preventing aspiration takes precedence.
- C: Promoting oral hygiene is important but not as urgent as preventing aspiration.
- D: Relieving the client's pain is essential, but ensuring their safety from aspiration is the priority.
A client is unconscious with a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?
- A. Kussmaul respirations
- B. Apneustic respirations
- C. Cheyne-Stokes respirations
- D. Stridor
Correct Answer: C
Rationale: The correct answer is C: Cheyne-Stokes respirations. This breathing pattern is characterized by alternating periods of deep, rapid breathing (hyperventilation) followed by periods of apnea. This pattern is often seen in clients with neurological or cardiac conditions. Kussmaul respirations (A) are deep and rapid breathing associated with metabolic acidosis. Apneustic respirations (B) are characterized by prolonged inhalation and short, insufficient exhalation. Stridor (D) is a high-pitched, noisy breathing sound caused by obstructed air flow in the upper airway, not associated with the described breathing pattern.
What does weight gain during the postoperative period indicate?
- A. Urine retention
- B. Healthy recovery
- C. Paralytic ileus
- D. Hypoxia
Correct Answer: C
Rationale: The correct answer is C because weight gain can indicate fluid retention due to paralytic ileus.