Nokea
Which of the following foods can cause diarrhea when eaten by a client with an ileostomy?
- A. eggs
- B. coffee
- C. fish
- D. garlic
Correct Answer: B
Rationale: Coffee might cause diarrhea in a client with an ileostomy. The other foods might cause odor.
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While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?
- A. I will assist you in arranging to have a medicine woman present.'
- B. We do not allow medicine women in exam rooms.'
- C. That does not make any difference in the outcome.'
- D. It is old-fashioned to believe in that.'
Correct Answer: A
Rationale: This statement reflects cultural awareness and acceptance that receiving support from a medicine woman is important to the client. The other statements are culturally insensitive and unprofessional.
A teenage client is admitted to the hospital because of an acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following organs?
- A. lungs
- B. liver
- C. kidneys
- D. adrenal glands
Correct Answer: B
Rationale: Acetaminophen is extensively metabolized in the liver. An acetaminophen overdose can lead to severe liver damage and even liver failure, which can be life-threatening. Choices A, C, and D are incorrect. Acetaminophen overdose does not typically cause life-threatening problems in the lungs, kidneys, or adrenal glands. While prolonged acetaminophen use may increase the risk of renal dysfunction, a single overdose primarily affects the liver.
A client has sustained a hyphema. What intervention should the nurse take?
- A. Have the client wear ear protectors in the future.
- B. Keep the client at bed rest, typically with the head of the bed propped up.
- C. Apply atropine eye drops.
- D. Apply an ice pack to the site of injury.
Correct Answer: B
Rationale: Initial care of the client involves preventing further damage and rebleeding. Clients are kept at bed rest if possible, usually with the head of the bed raised. TV watching is permitted but not reading. The use of atropine, ice, and eye shields are controversial, and a nurse should not administer a pharmacologic agent or thermal therapy without a physician's order.
A stool culture reveals Shigella. What corollary should the nurse recognize regarding this bacterial infection?
- A. People who have been in contact with the client need to be tested
- B. Shigella is an airborne infection
- C. Shigella is a bacteria sometimes found in stagnant water
- D. The nurse should wear a one-way breathing apparatus when giving client care
Correct Answer: C
Rationale: Shigella is transmitted via the oral-fecal route, often through contaminated water or food, including stagnant water, requiring hand washing and gloves for prevention.
Mrs. Owens is the 81-year-old mother of Jonathan, who is 54 years old. Jonathan has had schizophrenia since he was 16 years old. Which of Mrs. Owens's concerns is likely to predominate?
- A. "Will my retirement funds outlast me?"?
- B. "Who will handle my funeral arrangements?"?
- C. "What will become of Jonathan when I am gone?"?
- D. "How can I communicate effectively with Jonathan's physician?"?
Correct Answer: C
Rationale: The most prominent concern for Mrs. Owens is likely what will happen to her son, Jonathan, after she passes away. While retirement fund sustainability is important, it is not likely to be her primary concern. Funeral arrangements, although significant, are secondary to the welfare of her son with schizophrenia. The question of how to communicate with Jonathan's physician is less likely to be a predominant concern since Mrs. Owens has likely already addressed this issue over the 38 years of managing her son's care.