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Which statement by the client provides the best evidence that the client understands the principle of an exchange list for meal planning?
- A. I can eat one serving from each category on the exchange list per day.
- B. I record the patient's disease of food in each category are equal to one another.
- C. The number of servings from the exchange list is unlimited.
- D. I need to use the exchange list to determine the nutrition in food.
Correct Answer: B
Rationale: The exchange list groups foods with similar nutritional content, allowing equivalent substitutions.
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The client diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the client to assume to help decrease the pain?
- A. Recommend lying in the prone position with legs extended.
- B. Maintain a tripod position over the bedside table.
- C. Place in side-lying position with knees flexed.
- D. Encourage a supine position with a pillow under the knees.
Correct Answer: C
Rationale: Side-lying with knees flexed reduces abdominal tension, easing pancreatitis pain. Prone, tripod, and supine positions are less effective.
If the screening includes a measurement of postprandial blood glucose, the nurse is correct in explaining that blood will be drawn at which time?
- A. Approximately 2 hours before breakfast
- B. Approximately 2 hours after a meal
- C. Approximately 2 hours before bedtime
- D. Approximately 2 hours after fasting
Correct Answer: B
Rationale: Postprandial blood glucose is measured 2 hours after a meal to assess glucose metabolism.
Which interrelated concepts could be identified as actual or potential for a 56-year-old male client diagnosed with diabetes mellitus type 2? Select all that apply.
- A. Nutrition.
- B. Metabolism.
- C. Infection.
- D. Male reproduction.
- E. Skin integrity.
Correct Answer: A,B,C,E
Rationale: Nutrition, metabolism, infection, and skin integrity are impacted by type 2 diabetes due to dietary needs, glucose control, infection risk, and neuropathy. Male reproduction is less directly affected.
Which nursing diagnosis should the nursing team consider when developing this client's care plan?
- A. Activity intolerance
- B. Self-care deficit
- C. Ineffective breathing
- D. Impaired swallowing
Correct Answer: B
Rationale: Acromegaly can cause joint pain and muscle weakness, contributing to self-care deficits.
The client is diagnosed with acute pancreatitis. Which health-care provider's admitting order should the nurse question?
- A. Bedrest with bathroom privileges.
- B. Initiate IV therapy of D5W at 125 mL/hr.
- C. Weigh the client daily.
- D. Low-fat, low-carbohydrate diet.
Correct Answer: D
Rationale: A low-fat, low-carb diet is inappropriate during acute pancreatitis; clients are typically NPO to rest the pancreas. Bedrest, IV D5W, and weighing are appropriate.