Nokea
Which of the following side effects is associated with androgen therapy?
- A. Gynecomastia
- B. Increased appetite
- C. Virilization
- D. Euphoria
Correct Answer: C
Rationale: Androgen therapy promotes male secondary sexual characteristics leading to virilization (e.g. deepened voice facial hair). Gynecomastia is associated with estrogen and increased appetite or euphoria are not typical side effects of androgens.
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Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?
- A. Fresh fruit
- B. A milkshake
- C. Saltine crackers and peanut butter
- D. A ham and cheese sandwich
Correct Answer: B
Rationale: While fresh fruit is low in protein, a milkshake is a better choice as it provides carbohydrates and some protein in a form that is easier to digest, which is crucial for clients with cirrhosis to avoid ammonia buildup. A milkshake is appropriate as it provides carbohydrates, which are needed to prevent protein catabolism, and has lower protein content compared to options like peanut butter or ham, reducing the risk of ammonia accumulation. (C, D) Both saltine crackers with peanut butter and a ham and cheese sandwich are high in protein, which can increase ammonia levels, exacerbating hepatic encephalopathy.
The nurse is teaching a client with a history of lactose intolerance about dietary modifications. The nurse should tell the client to avoid:
- A. Dairy products
- B. High-fiber foods
- C. Lean meats
- D. Fresh fruits
Correct Answer: A
Rationale: Dairy products contain lactose, which causes gastrointestinal symptoms in lactose intolerance, so they should be avoided.
The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?
- A. Notify the physician.
- B. Record the reading as the only action.
- C. Turn the client and recheck the reading.
- D. Place the client supine.
Correct Answer: A
Rationale: An ICP of 66 mmHg is dangerously high (normal <20 mmHg), requiring immediate physician notification for intervention. Recording only (B), turning (C), or supine positioning (D) delays critical action.
Which diet would the nurse expect to see ordered for a patient with nephrotic syndrome?
- A. Low carbohydrate potassium
- B. Moderate protein
- C. Low calcium
- D. Increased potassium
Correct Answer: B
Rationale: Nephrotic syndrome causes proteinuria, leading to hypoalbuminemia. A moderate protein diet (0.8–1 g/kg/day) helps replace lost protein without overloading the kidneys. Low carbohydrate, low calcium, or increased potassium diets are not specific to nephrotic syndrome.
A 9-month-old infant was diagnosed with nonorganic failure to thrive. During her hospitalization, primary nurses were assigned to initiate all infant feedings. The infant's parents question why they cannot feed their own child. Which of the following responses would be most appropriate by the nurse?
- A. By assigning the same nurses to the child, the nurses can begin to learn the infant's cues and feeding behaviors.
- B. The same nurses will prevent parental fatigue and frustration.
- C. The same nurses will prevent infant fatigue and frustration.
- D. Primary nurses will ensure privacy.
Correct Answer: A
Rationale: Consistent primary care nurses can better interpret infant cues and note feeding behaviors, which is critical in managing nonorganic failure to thrive.