Nokea
Which diet selection by a client with a decubitus ulcer would indicate a clear understanding of the proper diet for healing of the ulcer?
- A. Tossed salad, milk, and a slice of caramel cake
- B. Vegetable soup and crackers, and a glass of iced tea
- C. Baked chicken breast, broccoli, wheat roll, and an orange
- D. Hamburger, French fries, and corn on the cob
Correct Answer: C
Rationale: Healing decubitus ulcers requires a diet high in protein, vitamins (especially C and A), and zinc. Baked chicken breast (protein), broccoli (vitamin C), wheat roll (carbohydrates), and an orange (vitamin C) provide these nutrients. Options A, B, and D lack sufficient protein or include less nutrient-dense foods (e.g., caramel cake, French fries).
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The doctor has ordered antithrombotic stockings to be applied to the legs of a client with peripheral vascular disease. The nurse knows antithrombotic stockings should be applied:
- A. Before the client arises in the morning
- B. With the client in a standing position
- C. After the client has bathed and applied lotion to the legs
- D. Before the client retires in the evening
Correct Answer: A
Rationale: Antithrombotic stockings should be applied before the client arises in the morning when edema is minimal, ensuring proper fit and maximum compression to promote venous return. Applying them later or after lotion can reduce effectiveness or cause skin irritation.
In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see?
- A. Clay-colored stools
- B. Steatorrhea stools
- C. Dark brown stools
- D. Blood-tinged stools
Correct Answer: B
Rationale: Clay-colored stools indicate dysfunction of the liver or biliary tract. In the early stages of cystic fibrosis, fat absorption is primarily affected resulting in fat, foul, frothy, bulky stools. Dark brown stools indicate normal passage through the colon. Blood-tinged stools indicate dysfunction of the gastrointestinal (GI) tract.
Diagnostic assessment findings for an infant with possible coarctation of the aorta would include:
- A. A third heart sound
- B. A diastolic murmur
- C. Pulse pressure difference between the upper extremities
- D. Diminished or absent femoral pulses
Correct Answer: D
Rationale: S1 and S2 in an infant with coarctation of the aorta are usually normal. S3 and S4 do not exist with this diagnosis. Either no murmur will be heard or a systolic murmur from an associated cardiac defect will be heard along the left upper sternal border. A diastolic murmur is not associated with coarctation of the aorta. Pulse pressure differences of >20 mm Hg exist between the upper extremities and the lower extremities. It is important to evaluate the upper and lower extremities with the appropriate-sized cuffs. Femoral and pedal pulses will be diminished or absent in infants with coarctation of the aorta.
Which finding in the patient's history contraindicates the use of Imitrex (sumatriptan) for the prevention of migraine headaches?
- A. Diabetes
- B. Angina
- C. Renal calculi
- D. Peptic ulcer disease
Correct Answer: B
Rationale: Sumatriptan (Imitrex) is a vasoconstrictor contraindicated in patients with angina due to the risk of coronary artery vasoconstriction and ischemia. Diabetes renal calculi and peptic ulcer disease are not contraindications for sumatriptan.
A 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find:
- A. A productive cough
- B. Expiratory stridor
- C. Drooling
- D. Crackles in the lower lobes
Correct Answer: C
Rationale: A productive cough is not associated with epiglottitis. Children with epiglottitis seldom have expiratory stridor. Inspiratory stridor is more common due to edema of the supraglottic tissues. Because of difficulty with swallowing, drooling often accompanies epiglottitis. Crackles are not heard in the lower lobes with epiglottitis because the infection is usually confined to the supraglottic structures.