Nokea
Which of the following interventions should be considered the highest priority when caring for June, who has hemiparesis secondary to a stroke?
- A. Position June in an upright lateral position
- B. Perform range of motion exercises
- C. Apply antiembolic stockings
- D. Use hand rolls or pillows for support
Correct Answer: C
Rationale: The correct answer is C, 'Apply antiembolic stockings'. In the case of a patient who has experienced a stroke and is suffering from hemiparesis, the highest priority intervention is to prevent further complications such as deep vein thrombosis (DVT), which can be life-threatening. Antiembolic stockings are used to increase venous blood flow velocity and reduce the risk of DVT. Choice 'A', positioning June in an upright lateral position, while important for overall care, is not the highest priority. Choice 'B', performing range of motion exercises, is an important part of recovery but not the immediate priority. Choice 'D', using hand rolls or pillows for support, is also a valuable intervention but does not address the most pressing risk of further complications.
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If it is determined that a child is being physically abused by a parent, what would be the most important goal for the nurse to establish with the family?
- A. The child and any siblings will reside in a secure environment
- B. The family will feel at ease in their relationship with the counselor
- C. The family will gain insight into their abusive behavior patterns
- D. The mother will learn to apply verbal discipline with her children
Correct Answer: A
Rationale: The primary objective when dealing with cases of child abuse is to ensure the safety of the child and any siblings. This means creating a secure environment free from harm, which is why choice 'A' is the correct answer. While choices 'B', 'C', and 'D' might be subsequent steps in a comprehensive plan to deal with the situation, they are not the immediate priority. Understanding abusive behavioral patterns or improving the relationship with the counselor will not directly lead to the child's safety. Likewise, teaching the mother to apply verbal discipline doesn't guarantee the child's safety if the abusive behavior continues. Therefore, these options are not the most important initial goal.
Which is the priority nursing diagnosis for a patient with an indwelling urinary catheter?
- A. Self-esteem disturbance
- B. Impaired urinary elimination
- C. Impaired skin integrity
- D. Risk for infection
Correct Answer: D
Rationale: The correct answer is 'D: Risk for infection.' An indwelling urinary catheter poses a significant risk for infection due to its invasive nature and the increased susceptibility to urinary tract infections. While 'B: Impaired urinary elimination' and 'C: Impaired skin integrity' may also be concerns for a patient with an indwelling urinary catheter, the immediate risk of infection is the priority. 'A: Self-esteem disturbance' is not typically a priority nursing diagnosis for a patient with an indwelling urinary catheter because the focus is primarily on infection prevention and management to ensure patient safety and well-being.
In which of the following conditions does a person need to sit, stand, or use multiple pillows when lying down?
- A. Orthopnea
- B. Dyspnea
- C. Eupnea
- D. Apnea
Correct Answer: A
Rationale: The correct answer is Orthopnea. Orthopnea is a medical condition in which a person has difficulty breathing while lying down. To alleviate this difficulty, the person may need to sit, stand, or use multiple pillows. On the other hand, Dyspnea refers to general shortness of breath which is not specifically related to the position of the body. Eupnea is the term for normal, unlabored breathing, and Apnea is a condition characterized by the cessation of breathing. Thus, none of these other choices directly relate to the need to adjust body position or use aids like multiple pillows to breathe comfortably when lying down.
Which food would benefit an anemic patient by increasing their intake?
- A. Beef
- B. Apples
- C. White bread
- D. Fish
Correct Answer: A
Rationale: An anemic patient would benefit from increasing their intake of beef. Beef is an excellent source of heme iron, which is critical for treating anemia. Heme iron is absorbed more readily by the body compared to non-heme iron found in plant-based foods. Apples and white bread, while healthy, do not contain significant amounts of heme iron. Fish, although it does contain iron, it's non-heme iron, which is not as efficiently absorbed by the body as heme iron, hence less effective in treating anemia.
What instruction should a nurse include when teaching a client who has recently been prescribed a low-sodium diet?
- A. Avoid foods such as smoked meats and frozen dinners.
- B. Select foods with less than 4g of sodium as indicated on food labels.
- C. Use soy sauce for flavoring foods instead of table salt.
- D. Processed and prepared foods are typically low in sodium.
Correct Answer: A
Rationale: The correct answer is A, which directs the client to avoid foods such as smoked meats and frozen dinners. These types of foods are typically high in sodium, making them unsuitable for a low-sodium diet. Option B is incorrect because foods with less than 4g of sodium might still be high in sodium for individuals on low-sodium diets. The daily recommended intake of sodium for a low-sodium diet is usually around 1.5g to 2g. Hence, 4g of sodium in a single food product can be excessive. Option C is incorrect as soy sauce, although a different source of flavor, is also high in sodium and should be used sparingly, if at all, in a low-sodium diet. Option D is incorrect because processed and prepared foods are usually not low in sodium. In fact, these foods often have high sodium content due to added salts and preservatives.