Which food should be avoided by the patient on a low-sodium diet?
- A. Apples
- B. Chicken
- C. Cheese
- D. Broccoli
Correct Answer: C
Rationale: Cheese is high in sodium and should be avoided by patients on a low-sodium diet. It is a common source of hidden sodium in many diets. Other high-sodium foods that should be limited or avoided include processed meats, canned soups, processed snacks, and condiments. Patients should focus on eating fresh fruits and vegetables, lean proteins like chicken (with no added salt), and whole grains to maintain a low-sodium diet.
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The nurse is using calipers to measure skinfold thickness over the triceps muscle in a school- age child. What is the purpose of doing this?
- A. To measure body fat
- B. To measure muscle mass
- C. To determine arm circumference
- D. To determine accuracy of weight measurement
Correct Answer: A
Rationale: Skinfold thickness measurements using calipers are commonly used in assessing body composition, specifically to estimate body fat percentage. By measuring skinfold thickness over the triceps muscle in combination with measurements from other sites on the body, healthcare professionals can estimate the amount of subcutaneous fat present. This information is valuable in evaluating an individual's overall body composition and health status. The triceps skinfold measurement is a commonly included site in body fat calculations, especially in school-age children, where it can provide insights into growth and development.
Which of the ff is a sign of urinary retention in older adults with a neurologic deficit?
- A. Amnesia
- B. Hypertension
- C. Hypotension
- D. A behaviour change
Correct Answer: D
Rationale: Urinary retention in older adults with a neurologic deficit can lead to a behavior change. This change may manifest as increased restlessness, agitation, or discomfort. It is important to be vigilant for any sudden alterations in behavior as they may indicate underlying complications such as urinary retention, which can be more challenging to identify in older individuals who may have difficulty communicating their symptoms clearly. Monitoring for behavior changes can help healthcare providers promptly address and manage urinary retention in these individuals.
The nurse should plan to teach the client with pancytopenia caused by a chemotherapy to;
- A. Begin a program of aggressive, strict mouth care
- B. Avoid traumatic injuries and exposure to any infection
- C. increase oral fluid intake to a minimum of 3000 ml daily
- D. Report any unusual muscle cramps or tingling sensations in the extremities
Correct Answer: B
Rationale: The correct action for the nurse to teach a client with pancytopenia caused by chemotherapy is to avoid traumatic injuries and exposure to any infection. Pancytopenia is a condition characterized by low levels of all blood cell types - red blood cells, white blood cells, and platelets. This leaves the individual vulnerable to infections, easy bruising, and bleeding. By advising the client to avoid traumatic injuries and exposure to infection, the nurse is helping to reduce the risk of further complications that can arise from low blood cell counts. This includes advising the client on taking precautions such as gentle handling to prevent skin injury, using a soft toothbrush for oral care, and avoiding contact with individuals who are sick to minimize the risk of infection.
What is the best age for solid food to be introduced into the infant's diet?
- A. 2 to 3 months
- B. 4 to 6 months
- C. When birth weight has tripled
- D. When tooth eruption has started
Correct Answer: B
Rationale: The American Academy of Pediatrics recommends introducing solid foods into an infant's diet between 4 to 6 months of age. At this stage, most infants have developed the necessary motor skills to start eating solid foods, such as being able to sit up and hold their head steady. Additionally, their digestive system has matured enough to handle solid foods. Introducing solid foods too early, such as at 2 to 3 months (Option A), can increase the risk of digestive issues and allergies. Waiting for tooth eruption (Option D) is not a reliable indicator as some infants may begin teething earlier or later than others. Waiting for the birth weight to triple (Option C) is not necessary as infants can start on solid foods once they reach the appropriate developmental stage around 4 to 6 months.
The nurse is caring for a school-age child who has had a cardiac catheterization. The child tells the nurse that the bandage is "too wet." The nurse finds the bandage and bed soaked with blood. What is the priority nursing action?
- A. Notify physician
- B. Apply new bandage with more pressure
- C. Place the child in Trendelenburg position
- D. Apply direct pressure above catheterization site
Correct Answer: D
Rationale: The priority nursing action in this situation is to apply direct pressure above the catheterization site to control the bleeding. This is important to prevent excessive blood loss and ensure the child's safety. The nurse should quickly address the issue of the soaked bandage and bed by applying direct pressure to the catheterization site to stop the bleeding. Once bleeding is controlled, the nurse should then notify the physician for further evaluation and treatment. Placing the child in Trendelenburg position is not necessary in this scenario, as the immediate focus should be on controlling the bleeding.