Nokea
Which of the following foods present a problem for a client diagnosed with Celiac Disease?
- A. Butter
- B. Oats or barley cereal
- C. Fresh vegetables
- D. Coffee or tea
Correct Answer: B
Rationale: Celiac disease, or celiac sprue, is a malabsorption disorder affecting the small intestine in which there is a problem with the ingestion of gluten, a protein normally found in grain products such as wheat, rye, oats, or barley. The other choices reflect substances that do not contain gluten and should not pose problems for a client with this disorder.
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The greatest time savers when planning client care include all of the following except:
- A. reacting to the crisis of the moment.
- B. setting goals.
- C. planning.
- D. specifying priorities.
Correct Answer: A
Rationale: The greatest time-savers when planning client care are activities that facilitate focus and completion of priority items. Time-savers include setting goals, establishing priorities, planning tasks, delegating where appropriate, re-assessment, and ongoing evaluation of needs.
The LPN is auscultating for bowel sounds and hears between 3 and 4 bowel sounds per minute. This is a somewhat expected finding for which of these clients?
- A. a 63-year-old female undergoing chemotherapy for breast cancer
- B. a 56-year-old female with dementia undergoing a swallow study
- C. a 34-year-old male with a PEG tube newly admitted for diabetic ketoacidosis
- D. a 45-year-old male recovering from a knee replacement under general anesthesia
Correct Answer: D
Rationale: When recovering from general anesthesia, hypoactive bowel sounds can be expected. For other clients, less than 5 bowel sounds per minute is an abnormal finding.
To remove hard contact lenses from an unresponsive client, the nurse should:
- A. gently irrigate the eye with an irrigating solution from the inner canthus outward.
- B. grasp the lens with a gentle pinching motion.
- C. don sterile gloves before attempting the procedure.
- D. ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens.
Correct Answer: D
Rationale: To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. The lens must be situated on the cornea, not the sclera, before removal. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean gloves are an option if drainage is present.
The LPN is observing a client using crutches for a leg injury. Which of these would indicate a need for more education?
- A. The client places the top padding 1-2 inches below the axilla with a firm grip on the handles.
- B. The client rests the axilla on the top padding and loosely grips the handles with hands.
- C. The client has a slight bend in the elbow when using the handles.
- D. When going down the stairs, the client leads with the injured leg.
Correct Answer: B
Rationale: Resting the axilla on the top of the crutch can cause nerve damage and the client should have a firm grip on the handles.
The nurse is developing guidelines to assist personnel in meeting the hygiene needs of clients with dementia. Which guidelines are appropriate for the nurse to include? Select all that apply.
- A. To limit the client's ability to physically resist, two staff should quickly bathe the client.
- B. Include music and dim lighting to create a calm environment when giving a bed bath.
- C. Allow clients who are willing and able to participate in some of the hygienic activities.
- D. Assess for and treat the client's pain before initiating hygienic cares with the client.
- E. Wash the client's hair and body separately if either activity causes the client distress.
Correct Answer: B,C,D,E
Rationale: B: Calm environments reduce agitation. C: Participation fosters cooperation. D: Pain management improves compliance. E: Separating tasks minimizes distress. A: Quick bathing increases agitation.