Nokea
You are preparing to discharge a client whose calcium level was low but is now just slightly within the normal range (9-10.5 mg/dL). Which statement by the client indicates the need for additional teaching?
- A. “I will call my doctor if I experience muscle twitching or seizures.”
- B. “I will make sure to take my vitamin D with my calcium each day.”
- C. “I will take my calcium pill every morning before breakfast.”
- D. “I will avoid dairy products,broccoli and spinach when I eat.”
Correct Answer: C
Rationale: The correct answer is C. Taking calcium supplements on an empty stomach can reduce their absorption. Calcium pills should be taken with food for optimal absorption. Options A, B, and D demonstrate good understanding of calcium management. Option A shows awareness of symptoms of hypocalcemia, B indicates proper supplementation, and D reflects knowledge of foods high in calcium that can interfere with supplement absorption.
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A client had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?
- A. Poor impulse control
- B. Inability to discriminate words and letters
- C. Deficits in the right visual field
- D. Motor retardation
Correct Answer: A
Rationale: The correct answer is A: Poor impulse control. When a client has a stroke involving the right cerebral hemisphere, it can affect their ability to regulate emotions and impulses. The right hemisphere is responsible for inhibiting impulsive behavior, so damage to this area can lead to poor impulse control. This can manifest as impulsivity, lack of judgement, and difficulty controlling emotions.
Summary of Incorrect Choices:
B: Inability to discriminate words and letters - This is typically associated with left cerebral hemisphere damage, not right hemisphere.
C: Deficits in the right visual field - This is associated with damage to the left occipital lobe, not the right hemisphere.
D: Motor retardation - Motor functions are controlled by the opposite side of the brain, so right hemisphere damage would typically affect the left side of the body, not motor function in general.
Describe the signs and symptoms of bipolar disorder.
- A. Increased alertness
- B. Lower immune response
- C. Faster metabolism
- D. Enhanced digestion
Correct Answer: D
Rationale: The correct answer is D because it is the most appropriate response based on physiological and medical principles.
While caring for a client receiving positive-pressure mechanical ventilation, which intervention should the nurse NOT implement to prevent complications?
- A. Elevate the head of the bed to at least 30°.
- B. Verify the prescribed ventilator settings daily.
- C. Administer pantoprazole as prescribed.
- D. Reposition the endotracheal tube to the opposite side of the mouth daily.
Correct Answer: D
Rationale: The correct answer is D. Repositioning the endotracheal tube to the opposite side of the mouth daily is not necessary and could potentially lead to complications such as accidental extubation or damage to the airway. A: Elevating the head of the bed helps prevent aspiration. B: Verifying ventilator settings daily ensures proper functioning. C: Administering pantoprazole helps prevent stress ulcers. In summary, D is incorrect because it is unnecessary and poses risks, while A, B, and C are important interventions to prevent complications associated with positive-pressure mechanical ventilation.
Which action should the nurse take to reduce the risk of ventilator-associated pneumonia in a client with an endotracheal tube receiving mechanical ventilation?
- A. Position the head of the client's bed flat
- B. Turn the client every 4 hours
- C. Brush the client's teeth with a suction toothbrush every 12 hours
- D. Provide humidity by maintaining moisture within the ventilator tubing
Correct Answer: C
Rationale: The correct answer is C: Brush the client's teeth with a suction toothbrush every 12 hours. This is crucial in reducing the risk of ventilator-associated pneumonia as it helps prevent the buildup of bacteria in the oral cavity, which can be aspirated into the lungs. Brushing the teeth regularly maintains oral hygiene, decreasing the chances of infection.
A: Positioning the head of the client's bed flat can increase the risk of aspiration and pneumonia.
B: Turning the client every 4 hours is important for preventing pressure ulcers but does not directly reduce the risk of ventilator-associated pneumonia.
D: Providing humidity within the ventilator tubing is important for preventing mucous plugs but does not directly address oral hygiene, which is key in preventing pneumonia.
Which factor may promote anxiety for a client undergoing a surgical procedure?
- A. Decreased mobility
- B. Unfamiliar environment
- C. Unclear expectations
- D. Decreased alertness
Correct Answer: C
Rationale: The correct answer is C because unclear expectations can increase anxiety in clients facing surgery.