Nokea
Which nursing problem is priority for the 76-year-old client diagnosed with gastroenteritis from staphylococcal food poisoning?
- A. Fluid volume deficit.
- B. Nausea.
- C. Risk for aspiration.
- D. Impaired urinary elimination.
Correct Answer: A
Rationale: Fluid volume deficit is the priority in elderly patients with gastroenteritis, as dehydration from vomiting and diarrhea poses significant risks. Nausea, aspiration, and urinary issues are secondary.
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The nurse is reviewing the health history of the client hospitalized with nonalcoholic fatty liver disease (NAFLD). Which finding should the nurse associate with this disease process?
- A. 70 years old at diagnosis
- B. Body mass index of 35
- C. History of recent antibiotic use
- D. Living in a colder climate
Correct Answer: B
Rationale: A. Adults in their forties are most at risk for NAFLD, not someone 70 years of age. B. The client’s BMI is 35; a BMI of greater than 30 indicates obesity. The risk for developing NAFLD is directly related to body weight and is a major complication of obesity. C. Antibiotic use has no influence on NAFLD development. D. Climate has no influence on NAFLD development.
The client's temperature rises to 38°C (100.4°F) on the first postoperative day following abdominal surgery. The nurse interprets this to be:
- A. indicative of a wound infection.
- B. a normal physiological response to the trauma of surgery.
- C. suggestive of a urinary tract infection.
- D. an indication of overhydration.
Correct Answer: B
Rationale: A slight temperature elevation (100.4°F) on the first postoperative day is a normal response to surgical trauma.
Which oral medication should the nurse question before administering to the client with peptic ulcer disease?
- A. E-mycin, an antibiotic.
- B. Prilosec, a proton pump inhibitor.
- C. Flagyl, an antimicrobial agent.
- D. Tylenol, a nonnarcotic analgesic.
Correct Answer: A
Rationale: E-mycin (erythromycin) can irritate the gastric mucosa and exacerbate peptic ulcer disease, so it should be questioned. Prilosec and Flagyl treat ulcers (especially H. pylori-related), and Tylenol is safe for pain relief.
Which task should the nurse delegate to the unlicensed assistive personnel (UAP) to improve the desire to eat in a 14-year-old client diagnosed with anorexia?
- A. Administer an antiemetic 30 minutes before the meal.
- B. Provide mouth care with lemon-glycerin swabs prior to the meal.
- C. Create a social atmosphere by interacting with the client.
- D. Encourage the client's parents to sit with the client during meals.
Correct Answer: D
Rationale: Encouraging parents to sit with the client is within the UAP’s scope and promotes a supportive eating environment. Administering medication, mouth care, and creating a social atmosphere require RN skills or specific training.
The weight loss clinic nurse identifies the concept of nutrition for a client diagnosed with obesity. Which interventions should the nurse implement? Select all that apply.
- A. Ask the client about previous diet attempts.
- B. Refer the client to the dietitian.
- C. Discuss maintaining a sedentary lifestyle.
- D. Weigh the client.
- E. Assist the client to set a realistic weight loss goal.
Correct Answer: A,B,D,E
Rationale: Asking about diets, dietitian referral, weighing, and setting goals support nutritional management for obesity. A sedentary lifestyle is contraindicated.