Nokea
An older man is being prepared for discharge after treatment for dehydration.
Which of the following statements, if made by the patient to the nurse, indicates that further teaching is needed?
- A. I should weigh myself daily.'
- B. I should drink fluids throughout the day.'
- C. I can use a measuring cup to find out how much I drink during the day.'
- D. I should let my doctor know if I get dizzy when I change positions.'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to dehydration. Be careful, this is a negative question. (1) correct-would only indicate overhydration, not response to dehydration (2) will help prevent recurrence of dehydration, should force fluids to 3,000 cc/day (3) would give good indication of total intake (4) would indicate postural hypotension resulting from volume deficit
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An African-American client is admitted with full thickness burns over 40% of his body. In addition to the CBC and complete metabolic panel, the physician is likely to request which additional lab work?
- A. Erythrocyte sedimentation rate
- B. Indirect Coombs
- C. C reactive protein
- D. Sickledex
Correct Answer: D
Rationale: Sickle cell anemia and sickle cell trait are more prevalent in African American clients. The Sickledex test detects the presence of sickle cell anemia and sickle cell trait. Trauma can trigger a sickle cell crisis, which would complicate the treatment of the client. Answers A and C indicate inflammation, so they are incorrect. Answer B is incorrect because it detects circulating antibodies against RBCs.
The nurse is caring for a client with a history of osteoporosis.
- A. Which intervention is most effective for preventing fractures in a client with osteoporosis?
- B. Encourage weight-bearing exercises.
- C. Administer vitamin C supplements.
- D. Restrict calcium intake.
- E. Encourage bed rest to prevent falls.
Correct Answer: A
Rationale: Weight-bearing exercises strengthen bones, reducing fracture risk in osteoporosis. Vitamin C is less critical than calcium and vitamin D, calcium restriction worsens bone loss, and bed rest increases bone resorption.
A client with a cholesterol level of $240 \mathrm{mg}$ is instructed to modify his diet. Which of the following diets provides a low-cholesterol, low-saturated fat breakfast?
- A. Oatmeal, skim milk, toast with margarine, orange juice, coffee
- B. French toast, margarine, syrup, crisp bacon, coffee
- C. Pancake, margarine, syrup, sausage, fresh fruit, tea
- D. Toasted bagel, cream cheese, poached egg, coffee
Correct Answer: A
Rationale: Oatmeal, skim milk, and margarine are low in cholesterol and saturated fat, unlike bacon, sausage, or cream cheese.
The nurse is caring for an adult who has kidney stones. Which action is essential for the nurse to take?
- A. Take blood pressure frequently
- B. Keep the client on bed rest
- C. Position the client supine
- D. Strain all urine
Correct Answer: D
Rationale: Straining urine captures kidney stones for analysis, guiding treatment. Blood pressure, bed rest, or positioning are not primary.
A 33-year-old woman comes to the local outpatient clinic for complaints of dizziness and palpitations. Her physical exam and laboratory results are normal. She reports that the company she owns is on the verge of bankruptcy.
Which of the following responses, if made to the client by the nurse, would be BEST?
- A. When did you first notice these symptoms?'
- B. Have you shared this information with anyone?'
- C. Are you concerned about your financial difficulties?'
- D. Would you like to discuss your situation with me?'
Correct Answer: A
Rationale: Strategy: 'BEST' indicates there may be more than one correct response. Remember therapeutic communication. (1) correct-open-ended question, encourages client to discuss when problems occurred (2) yes/no question, nontherapeutic, doesn't encourage discussion of symptoms (3) yes/no question, nontherapeutic, too confrontational, does not encourage discussion (4) yes/no question, nontherapeutic