Nokea
Which of the ff diets does the nurse recommend for clients with hypertension under the physicians guidance?
- A. The Food Guide Pyramid
- B. The South Beach Diet
- C. The Step One Diet
- D. The Dash diet
Correct Answer: D
Rationale: Step 1: The DASH diet is specifically designed to help lower blood pressure, making it the most appropriate choice for clients with hypertension.
Step 2: The DASH diet emphasizes fruits, vegetables, whole grains, lean proteins, and low-fat dairy, all of which are beneficial for managing hypertension.
Step 3: The diet also limits sodium intake, which is crucial for controlling blood pressure.
Step 4: The other options (A, B, and C) do not have the same evidence-based focus on hypertension management and may not be as effective in lowering blood pressure.
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The nursing care for the client in addisonian crisis should include which of the following interventions?
- A. Encouraging independence with activities of daily living (ADL)
- B. Allowing ambulation as tolerated
- C. Offering extra blankets and raising the heat in the room to keep the client warm
- D. Placing the client in a private room
Correct Answer: C
Rationale: The correct answer is C because in Addisonian crisis, the client experiences adrenal insufficiency leading to decreased cortisol levels and impaired stress response. Offering extra blankets and raising room temperature helps prevent hypothermia, as clients in crisis are unable to regulate body temperature. Encouraging independence with ADLs (choice A) and ambulation (choice B) are not priorities as the client is in a critical state. Placing the client in a private room (choice D) is not directly related to managing Addisonian crisis.
The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
- A. Etiology
- B. Nursing diagnosis
- C. Collaborative problem
- D. Defining characteristic
Correct Answer: C
Rationale: The correct answer is C: Collaborative problem. In the given diagnostic statement, "Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate," the nurse needs to revise the mention of collaborative problem. The collaborative problem is a health issue that requires the expertise of multiple healthcare providers, whereas the statement provided focuses on a nursing diagnosis related to physical mobility impairment. The etiology (cause), nursing diagnosis, and defining characteristic are all relevant to the nursing diagnostic statement and do not need revision. The collaborative problem aspect is not appropriate in this context as it does not fit the criteria for a collaborative problem.
The majority of lumbar disc herniations occur at the level of:
- A. L1 –L2
- B. L4-L5
- C. L3-L4
- D. S1-S2
Correct Answer: B
Rationale: The correct answer is B: L4-L5. This is because the L4-L5 intervertebral disc segment experiences the highest amount of mechanical stress and mobility in the lumbar spine, making it more prone to herniation. Additionally, nerve roots at this level innervate the lower extremities, making it a common site for symptoms such as sciatica. Choices A, C, and D are incorrect because herniations at those levels are less common due to lower mechanical stress and mobility compared to L4-L5.
Which of the ff should qualify as an abnormal result in a Romberg test?
- A. Hypotension
- B. Swaying, losing balance, or arm drifting
- C. Sneezing and wheezing
- D. Excessive cerumen in the outer ear
Correct Answer: B
Rationale: Step-by-step rationale:
1. In a Romberg test, the patient stands with feet together and eyes closed to assess proprioception.
2. Swaying, losing balance, or arm drifting indicates impaired proprioception, suggesting a positive Romberg sign, which is abnormal.
3. Hypotension (choice A) is not directly related to the Romberg test.
4. Sneezing and wheezing (choice C) are unrelated to the test.
5. Excessive cerumen in the outer ear (choice D) does not affect proprioception.
Summary: Choice B is correct as it directly relates to impaired proprioception, which is abnormal in a Romberg test. Choices A, C, and D are incorrect as they are unrelated to the purpose of the test.
A patient asks the nurse what is CYSTOCLYSIS? The best explanation would be:
- A. to increase bladder atony
- B. to maintain patency of the foley
- C. to remove blood clots from the bladder catheter
- D. to lower the specific gravity of the urine
Correct Answer: B
Rationale: Rationale:
B is correct because cystoclisis is the process of maintaining patency of a foley catheter by irrigating it with a sterile solution. This prevents blockages and promotes proper drainage.
A, C, and D are incorrect because cystoclisis is not related to increasing bladder atony, removing blood clots, or altering urine specific gravity.