Nokea
An eight-year-old with cystic fibrosis (CF).
Which of the following dietary requirements should be considered?
- A. High protein, high fat, and high calories.
- B. High protein, low fat, and high calories.
- C. Low protein, low fat, and low carbohydrate.
- D. High protein, high fat, and low carbohydrate.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) contains high fat (2) correct-impaired inTest inal absorption due to cystic fibrosis necessitates a diet higher in protein and calories; fat is decreased because it may interfere with absorption of other nutrients (3) not adequate for this child (4) contains high fat
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The home care nurse is instructing a client recently diagnosed with tuberculosis.
- A. What is the most important instruction for a client with tuberculosis?
- B. During the first two weeks of treatment, the client should cover his mouth and nose when he coughs or sneezes.
- C. It is necessary for the client to wear a mask at all times to prevent transmission of the disease.
- D. The family should support the client to help reduce feeling of low self-esteem and isolation.
- E. The client will be required to take prescribed medication for a duration of 6-9 months.
Correct Answer: D
Rationale: Adherence to a 6-9 month medication regimen is critical to cure tuberculosis and prevent drug resistance. While respiratory precautions, family support, and masks are important, long-term medication compliance is the most essential for treatment success.
The nurse is caring for a 1 year-old child who has 6 teeth. What is the best way for the nurse to give mouth care to this child?
- A. Using a moist soft brush or cloth to clean teeth and gums
- B. Swabbing teeth and gums with flavored mouthwash
- C. Offering a bottle of water for the child to drink
- D. Brushing with toothpaste and flossing each tooth
Correct Answer: A
Rationale: Using a moist soft brush or cloth to clean teeth and gums. The nurse should use a soft cloth or soft brush to do mouth care so that the child can adjust to the routine of cleaning the mouth and teeth.
A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to 'see old buddies.' The nurse understands that the client's behaviors are warning signs to indicate that the client may be
- A. Headed for relapse
- B. Feeling hopeless
- C. Approaching recovery
- D. In need of increased socialization
Correct Answer: A
Rationale: Headed for relapse. These behaviors suggest a return to risky environments and habits, indicating potential relapse.
The nurse is caring for clients on the neurology unit.
- A. What is the most appropriate action for the nurse to take after noting a client suddenly developed a fixed and dilated pupil?
- B. Reassess in five minutes.
- C. Check the client’s visual acuity.
- D. Lower the head of the client’s bed.
- E. Contact the physician.
Correct Answer: D
Rationale: A fixed and dilated pupil is a neurological emergency, often indicating increased intracranial pressure or brain herniation. Immediate physician notification is critical to initiate interventions. Reassessing later delays care, checking visual acuity is irrelevant, and lowering the bed could worsen intracranial pressure.
Which of the following should be included in the discharge teaching of a client with a unilateral adrenalectomy?
- A. The client's need to pay close attention to skin care
- B. The client's need to restrict dietary intake of sodium and protein
- C. The client's need to recognize signs of hypoglycemia
- D. The client's need for daily steroid medication
Correct Answer: D
Rationale: Unilateral adrenalectomy may impair cortisol production, requiring lifelong steroid replacement. Skin care, dietary restrictions, and hypoglycemia are not primary concerns.