An infant is born with a cleft lip. What nursing intervention is unique to infants with cleft lip? 1. Changing the infant's position often 2. Using modified techniques for feeding 3. Monitoring the infant's daily intake and output 4. Keeping the infant's head elevated during feedings
Using modified techniques for feeding Infants with a cleft in the lip are unable to suck like other newborns because they cannot form a vacuum to draw milk from the nipple. Frequent position changes are common for all infants, not just ones with cleft lip. Monitoring of intake and output is not necessary because hydration is maintained once a feeding method has been established. All infants should be fed with the head elevated to avoid pooling of milk in the mouth, which could result in aspiration.
The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention? 1. Provide perineal care. 2. Turn and position the client. 3. Give a complete bed bath. 4. Document the bowel movement.
Provide perineal care. Providing perineal care helps to preserve skin integrity for the client who is incapable of providing self-care. Turning and positioning the client who has decreased physical mobility after hip surgery is important in preventing skin breakdown, but it is not an immediate client need. Giving a complete bed bath is not necessary after each bowel movement because only the perineal area is typically soiled. Documenting the bowel movement should be done only after meeting immediate needs of the client.
A client has a hiatal hernia. The client is 5 feet 3 inches tall (163 cm) and weighs 160 pounds (72.6 kg). Which information should the nurse include when discussing prevention of esophageal reflux? 1. Increase your intake of fat with each meal. 2. Lie down after eating to help your digestion. 3. Reduce your caloric intake to foster weight reduction. 4. Drink several glasses of fluid during each of your meals.
Reduce your caloric intake to foster weight reduction. Weight reduction decreases intraabdominal pressure, thereby decreasing the tendency to reflux into the esophagus. Fats decrease emptying of the stomach, extending the period that reflux can occur; fats should be decreased. Lying down after eating increases the pressure against the diaphragmatic hernia, increasing symptoms. Drinking several glasses of fluid during each meal will increase pressure; fluid should be discouraged with meals.
During her first prenatal visit the client reports that her last menstrual period began on April 15. According to Nägele rule, what is the expected date of delivery (EDD)? 1. January 8 2. January 22 3. February 8 4. February 22
January 22 To determine EDD with the use of Nägele rule, subtract 3 months from the date of the last menstrual period and add 7 days. January 8 is 2 weeks too early according to this formula. February 8 is too late. February 22 would be 1 month past the true EDD.
A client with gastroesophageal reflux disease (GERD) is being treated with dietary management. The client states, "I like to have a glass of juice every day." Which juice will the nurse recommend? 1. Apple 2. Orange 3. Tomato 4. Grapefruit
Apple Apple juice is nonirritating to the stomach and intestine. Orange juice, tomato juice, and grapefruit juice are acidic juices that decrease the pH of the stomach and irritate the gastrointestinal mucosa.
A nurse is caring for a client with a diagnosis of renal calculi secondary to hyperparathyroidism. Which type of diet should the nurse explore with the client when providing discharge information? 1. Low purine 2. Low calcium 3. High phosphorus 4. High alkaline ash
Low calcium A low calcium intake is recommended. Calcium and phosphorus are components of these stones; foods high in calcium and phosphorus should be avoided. Low purine and high alkaline ash diets are indicated for clients with gout.
A client with myasthenia gravis experiences generalized weakness. What is most important when planning this client's nursing care? 1. Maintaining bed rest 2. Providing frequent rest periods 3. Reassuring the client that there are many tasks that still can be performed 4. Arranging for a relative to be present
Providing frequent rest periods Spacing activities encourages maximum functioning within the limits of the client's strength and fatigue. Bed rest and limited activity may lead to muscle atrophy and calcium depletion and should be avoided. Although pointing out things the client can do is important, this does not address the client's concerns. Arranging for a relative to be present is unnecessary if the client is observed closely by the nursing staff; however, it should be permitted if requested by the client or family.
A nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation? 1. Neurologic 2. Wound 3. Pain 4. Skin
Pain Assessment of pain must be performed before beginning a potentially painful procedure such as a wound irrigation. A neurologic check is not necessary unless the client’s neurologic status has worsened since the stroke. Both skin and wound checks can be assessed once client comfort has been determined and handled.
A nurse instructs a client with viral hepatitis about the type of diet that should be ingested. Which lunch selected by the client indicates understanding about dietary principles associated with this diagnosis? 1. Turkey salad, french fries, sherbet 2. Cottage cheese, mixed fruit salad, milkshake 3. Salad, sliced chicken sandwich, gelatin dessert 4. Cheeseburger, tortilla chips, chocolate pudding
Salad, sliced chicken sandwich, gelatin dessert The diet should be high in carbohydrates, with moderate protein and fat content. Salad, chicken and gelatin is the best choice. Turkey salad, french fries, and sherbet are too high in fat. Cottage cheese, mixed fruit salad, and a milkshake are dairy products and may cause lactose intolerance; the virus injures the intestinal mucosa. Cheeseburger, tortilla chips, and chocolate pudding are too high in fat.
Which nursing theory focuses on the client’s self-care needs? 1. Roy’s theory 2. Orem’s theory 3. Watson’s theory 4. Leininger’s theory
Orem’s theory Orem’s self-care deficit theory focuses on the client’s self-care needs. According to Roy’s theory, the goal of nursing is to help a person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. Watson’s theory of transpersonal caring defines the outcome of nursing activity with regards to the humanistic aspects of life. The major concept of Leininger’s theory is cultural diversity, with the goal of nursing care being to provide the client with culturally specific nursing care.
A primary healthcare provider prescribes a low-sodium, high-potassium diet for a client with Cushing syndrome. Which explanation should the nurse provide to the client about the need to follow this diet? 1. "The use of salt probably contributed to the disease." 2. "Excess weight will be gained if sodium is not limited." 3. "The loss of excess sodium and potassium in the urine requires less renal stimulation." 4. "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium."
"Excessive aldosterone and cortisone cause retention of sodium and loss of potassium." Clients with Cushing syndrome must limit their intake of salt and increase their intake of potassium. The kidneys are retaining sodium and excreting potassium. An excessive secretion of adrenocortical hormones in Cushing syndrome, not increased or high sodium intake, is the problem. Although sodium retention causes fluid retention and weight gain, the need for increased potassium also must be considered. Because of steroid therapy, excess sodium may be retained, although potassium may be excreted.
An infant has been admitted with failure to thrive (FTT). The nurse knows that more education is needed when one of the parents makes what statement? 1. "I can double the amount of water in the formula to save money." 2. "I need to hold her head up a little higher than her stomach when I feed her." 3. "I need to burp the baby when the feeding is done to get rid of swallowed air." 4. "I need to make sure that the formula is in the nipple so she doesn't swallow so much air."
"I can double the amount of water in the formula to save money." Doubling the amount of water in the formula reduces the baby's caloric intake. Holding the head up, burping the baby, and making sure that formula is in the nipple are all ways to increase caloric intake and reduce the chance of postfeeding vomiting due to air swallowing.
After abdominal surgery a client reports pain. What action should the nurse take first? 1. Reposition the client. 2. Obtain the client's vital signs. 3. Administer the prescribed analgesic. 4. Determine the characteristics of the pain.
Determine the characteristics of the pain. The exact nature of the pain must be determined to distinguish whether or not it is a result of the surgery. Repositioning the client, obtaining the client's vital signs, and administering the prescribed analgesic should be done later; the first action is to determine the cause of the pain.
A nurse is caring for an 18-month-old toddler. What findings is the nurse likely to notice? 1. The toddler’s urine appears golden yellow in color. 2. The toddler excretes 400 to 500 mL of urine every day. 3. The toddler can hold urine for a period of 1 to 2 hours. 4. The toddler is unable to communicate his or her sense of urgency.
The nurse will notice that at the age of 18 months the child is able to hold urine for 1 to 2 hours. The urine of infants and young children appears light yellow and clear. A 6-month-old infant who weighs 13 to 18 pounds excretes 400 to 500 mL of urine daily. A toddler is able to communicate his or her sense of urgency.
When a nurse requests that a client's pain intensity be rated on a scale of 0 to 10, the client states that the pain is "99." How does the nurse interpret the client’s behavior? 1. Needs the instructions to be repeated 2. Requires an intervention immediately 3. Does not understand the numeric scale 4. Is using humor to get the nurse's attention
Requires an intervention immediately The client reported a number as instructed but chose a number beyond the stated intensity scale. When numbers above 10 are identified, clients are communicating that the pain is excessive; immediate nursing action is indicated. It is not likely that the client misunderstood the instructions or does not understand the numeric scale; the client reported a number as instructed but chose a number beyond the stated intensity scale. The client has the nurse's attention; the use of humor is not commonly associated with clients in pain.
The practitioner prescribes a diet high in vitamin B1 (thiamine) for a client with a long history of alcohol abuse. The nurse concludes that the client understands the teaching about foods high in thiamine when the client makes which statement? 1. "I'll choose fish, aged cheese, and breads." 2. "I'll choose lean beef, organ meat, and nuts." 3. "I'll choose poultry, milk products, and eggs." 4. "I'll choose green vegetables, lentils, and citrus fruits."
"I'll choose lean beef, organ meat, and nuts." Lean beef, organ meats, and nuts all provide high levels of thiamine; other sources include legumes, whole and enriched grains, and lean pork. Of fish, aged cheese, and bread, only fish is considered a source of thiamine. Of poultry, milk products, and eggs, only eggs are considered a source of thiamine; this list contains sources of protein. Of green vegetables, lentils, and citrus fruits, only lentils (legumes) are considered a source of thiamine; most vegetables contain only traces of thiamine, and citrus fruits provide vitamin C.
Which domain of the Nursing Interventions Classification (NIC) Taxonomy includes care that supports the health of the community? 1. Domain 1 2. Domain 2 3. Domain 6 4. Domain 7
Domain 7 Domain 7 of the Nursing Interventions Classification (NIC) taxonomy includes care that supports the health of the community. Domain 1 includes interventions that support physical functioning. Domain 2 includes care that supports homeostatic regulation. Domain 6 incorporates interventions that support the effective use of the healthcare delivery system.
A client who had a brain attack (stroke) is admitted to the hospital with right-sided hemiplegia. For what reason does the nurse recognize the importance of identifying restrictions of mobility or neuromuscular abnormalities? 1. Shortening and eventual atrophy of the muscles will occur. 2. Hypertrophy of the muscles eventually will result from disuse. 3. Rigid extension can occur, making therapy painful and difficult. 4. Decreased movement on the affected side predisposes the client to infection.
Shortening and eventual atrophy of the muscles will occur. Shortening and eventual atrophy of muscles occur, resulting in contractures. Muscles will atrophy, not hypertrophy, from disuse. Flexion contractions, not extension rigidity, occur. Hemiplegia does not predispose to infection but to atrophy and contractures.
What should the nurse do to prevent deformities of the knee in a client with an exacerbation of arthritis? Select all that apply. 1. Encourage motion of the joint. 2. Maintain a knee brace on the leg. 3. Keep the client on a regimen of bed rest. 4. Maintain joints in functional alignment when resting. 5. Immobilize the joint with pillows until pain subsides.
Encourage motion of the joint. Maintain joints in functional alignment when resting. Exercise of involved joints is important to maintain optimal mobility and prevent buildup of calcium deposits. Functional alignment places the least strain on joints, muscles, and tendons. Immobilization causes loss of joint mobility and contractures. Immobility promotes the development of contractures. Immobilization with pillows promotes the development of contractures.
Two days after abdominal surgery a client experiences extensive flatus. The nurse administers the Harris flush (Harris drip). Which finding indicates a therapeutic effect? 1. Client has a bowel movement. 2. Client's returns are finally clear. 3. Client's abdomen is less distended. 4. Client is able to retain a half liter of fluid.
Client's abdomen is less distended. The Harris flush removes accumulated gas in the intestine, which reduces distention of the abdomen. Stimulating evacuation is not the purpose of a Harris flush; a bowel movement indicates that an enema, not a Harris flush, was effective. The returns of a Harris flush usually contain small amounts of fecal material; the technique is not used for cleansing the bowel. The fluid is not retained; small amounts are instilled slowly and then permitted to return slowly, taking gas with it.
After a mild brain attack (cerebrovascular accident, CVA) a client has difficulty grasping objects with the dominant hand. To increase hand mobility and strength, what specific range-of-motion exercise should the nurse teach the client? 1. Eversion 2. Supination 3. Opposition 4. Circumduction
Opposition Opposition occurs when the thumb, a saddle joint, sequentially touches the tip of each finger of the same hand; the thumb joint movements involved are abduction, rotation, and flexion. Strengthening the thumb facilitates grasping and holding objects in the hand. Eversion involves turning the sole of the foot outward by moving the ankle joint, which is a gliding joint. Supination involves moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body. Circumduction involves movement of the distal part of the bone in a circle while the proximal end remains fixed; circumduction is used with ball-and-socket joints, such as the shoulder and hip.
Which finding indicates the development of a complication resulting from bilateral cephalohematomas? 1. Urine output 2. Skin color 3. Glucose level 4. Rooting/sucking reflex
Skin color Cephalohematomas are gradually absorbed. As the hematoma resolves, hemolysis of red blood cells occurs, and jaundice may result. Urine output, glucose level, and the rooting/sucking reflex are not affected by a cephalohematoma.
A client with Cushing syndrome asks why a low-sodium, high-potassium diet has been prescribed. What is the best response by the nurse? 1. "The client will gain excessive weight if sodium is not limited." 2. "An inadequate intake of potassium contributed to the disease." 3. "This type of diet increases emotional stability." 4. "Excessive aldosterone and cortisone cause the retention of sodium and loss of potassium."
"Excessive aldosterone and cortisone cause the retention of sodium and loss of potassium." Clients with Cushing syndrome or those receiving cortical hormones must limit their intake of sodium and increase their intake of potassium, because the kidneys are retaining sodium and excreting potassium. Although sodium retention causes fluid retention and weight gain, the need for increased potassium must be considered as well. An excessive secretion of adrenocortical hormones in Cushing syndrome, not inadequate potassium intake, is the problem. This type of diet has no direct effect on the client's emotional status.
A client who has been in a coma for 2 months is being maintained on bed rest. At which angle will the nurse place the head of the bed to prevent the effects of shearing force? 1. 30 degrees 2. 45 degrees 3. 60 degrees 4. 90 degrees
30 degrees Shearing force occurs when two surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and cause this phenomenon. Angles of 45
The nurse provides a list of foods to prevent constipation to a client who has a history of constipation. Which statement from the client indicates the nurse needs to follow up? 1. "I should eat eggs." 2. "I should eat beans." 3. "I should eat fresh fruits." 4. "I should eat steamed vegetables."
"I should eat eggs." Eggs do not contain roughage and will not prevent constipation. Beans contain both soluble and insoluble fibers that promote intestinal peristalsis, preventing constipation. Raw fruits and steamed vegetables contain roughage that promotes intestinal peristalsis, preventing constipation.
A primary healthcare provider has prescribed pyrazinamide to a client with tuberculosis. Which instruction by the nurse will be beneficial to the client? Select all that apply. 1. "Avoid drinking alcoholic beverages." 2. "Drink at least 8 ounces of water with the medication." 3. "Your soft contact lenses will be stained permanently." 4. "Darkening of the urine is normal while you are using this drug." 5. "Be sure to report any changes in vision such as diminished color perception."
"Avoid drinking alcoholic beverages." "Drink at least 8 ounces of water with the medication." A client undergoing pyrazinamide therapy may require extra fluids to help prevent uric acid formation from precipitating and causing gout or kidney problems. Therefore the client should drink at least 8 ounces of water with the medication. The client should also avoid alcoholic beverages, which could potentiate liver toxicity. Staining is a common problem with rifampin, not pyrazinamide. The client should also report any darkening of urine because this may be a sign of liver toxicity or damage. The client should report any vision changes if he or she is taking etambutol.
After a gastrojejunostomy (Billroth II) for cancer of the stomach, a client progresses to a regular diet. After eating lunch, the client becomes diaphoretic and has palpitations. What does the nurse conclude is the probable cause of these clinical manifestations? 1. Intolerance to fatty foods 2. Dehiscence of the surgical incision 3. Extracellular fluid shift into the bowel 4. Diminished peristalsis in the small intestine
Extracellular fluid shift into the bowel Hypertonic food increases osmotic pressure and pulls fluid from the intravascular compartment into the intestine (dumping syndrome). Increased carbohydrates, not fats, are responsible for the increased osmotic pressure often associated with dumping syndrome. Dehiscence is separation of the wound edges, usually accompanied by a gush of pink-tinged fluid. Although peristalsis may be decreased because of surgery, this decrease will not account for the client's clinical manifestations.
A client with a suspected kidney disorder reports flank pain. Which nursing interventions should be conducted while performing flank assessment? Select all that apply. 1. Percussing the tender flank first 2. Forming both hands into a clenched fist 3. Asking the client to assume a sitting position 4. Placing one hand flat on costovertebral angle (CVA) 5. Delivering a firm hand thump over the lower abdomen
Asking the client to assume a sitting position Placing one hand flat on costovertebral angle (CVA) While assessing the flank regions of a client with a suspected kidney disorder, the nurse should ask the client to assume a sitting position. The nurse should place one hand on the costovertebral angle (CVA) during assessment. The nurse should first percuss the nontender flank; percussing the tender flank first may aggravate the client’s pain. A clenched fist should be formed with one hand. The nurse should deliver a firm hand thump over the costovertebral angle (CVA).
A client with dementia is admitted with a fractured hip after a fall at home. The client’s family member witnessed the fall. Four hours after admission, the client’s blood pressure increases to a moderately severe hypertensive level. The client pulls on the bedclothes continuously. The client’s family member asks for pain medication for the client. What does the nurse concludes? 1. The client has the need to go to the bathroom. 2. The client may be in pain and unable to respond appropriately. 3. The family member may be trying to keep the client overmedicated. 4. The family member feels guilty about the fall and wants to keep the client pain free.
The client may be in pain and unable to respond appropriately. The client’s dementia indicates that the client has problems with thought processes and may not be able to interpret or communicate the presence of pain. An increased blood pressure, caused by central nervous system stimulation, and pulling on the bedclothes suggest that the client is in pain. The client may have a need to go to the bathroom, but it is more likely that the client has pain that he or she is unable to communicate. There is no evidence that the family member wants the client overmedicated or has feelings of guilt.
The parents of a newborn with phenylketonuria (PKU) need help and support in adhering to specific dietary restrictions. They ask the nurse, "How long will our child have to be on this diet?" How should the nurse respond? 1. "We're still not sure; you should discuss this with your healthcare provider." 2. "If your baby does well, foods containing protein can gradually be introduced." 3. "Your child needs to be on this diet at least through adolescence and into adulthood." 4. "This is a lifelong problem, and it is recommended that dietary restrictions be continued for life."
"This is a lifelong problem, and it is recommended that dietary restrictions be continued for life." The nurse should respond truthfully and provide the parents with up-to-date information. For optimal metabolic control to be achieved, it is recommended that people with classic PKU eat a low-phenylalanine diet for life.
What should be included in a plan of care to limit the development of hyperbilirubinemia in the breastfed neonate? 1. Encouraging more frequent breastfeeding during the first 2 days 2. Instituting phototherapy for 30 minutes every 6 hours for 3 days 3. Substituting formula feeding for breastfeeding on the second day 4. Supplementing breastfeeding with glucose water during the first day
Encouraging more frequent breastfeeding during the first 2 days More frequent breastfeeding stimulates more frequent evacuation of meconium, thereby preventing resorption of bilirubin into the circulatory system. Phototherapy is the treatment for hyperbilirubinemia, and it is maintained continuously; it does not prevent the development of hyperbilirubinemia. It is not necessary to feed the infant formula. Early breastfeeding tends to keep the bilirubin level low by stimulating gastrointestinal activity. Increasing water intake does not limit the development of hyperbilirubinemia, because only small amounts of bilirubin are excreted by the kidneys.
A 6-year-old child with glomerulonephritis has a fluid restriction of 600 mL/24 hr. How can the nurse help the child cope with this limitation? 1. By withholding fluids from 7 pm to 7 am 2. By dividing fluids equally among the shifts 3. By allowing fluids as desired until the limit is reached 4. By offering fluids in medicine cups throughout the child's waking hours
By offering fluids in medicine cups throughout the child's waking hours Offering fluids in a full 1-oz (30 mL) medicine cup allows the child to drink without a long time between drinks; a full container, even if it is small, fosters the illusion that the child is receiving more. Although fluids may be limited during sleeping hours, 12 hours is too long for a young child to go without fluids. When fluid is limited, a smaller amount should be apportioned to the sleeping hours. If the child is allowed to drink as much as desired until the limit is reached, 15 to 20 hours might elapse before any fluid is permitted again.
The mother of a preschooler with acute glomerulonephritis (AGN) asks the nurse whether her child will have to stay in bed. What does the nurse say about the need for bed rest? 1. No longer a necessary part of the treatment plan 2. Limited to 72 hours after the start of antihypertensive therapy 3. Required for 3 weeks and does not depend on the response to therapy 4. Needed until the blood pressure decreases and the hematuria has lessened
No longer a necessary part of the treatment plan Bed rest is no longer required. Activity limitations are not enforced. Usually the child is content to stay in bed during the acute phase. The activity level depends on the response to therapy. Children will increase their activity as they begin to feel better.
The nurse is caring for a client during the transition phase of labor. The nurse determines that the client has entered the second stage of labor when what happens? 1. There is restlessness and thrashing about. 2. There are complaints of sudden and intense back pain. 3. The client reports that she feels the urge to move her bowels. 4. The client asks for medication to relieve pain from the strong contractions.
During the second stage the presenting part is low in the birth canal and may cause strong sensations of pressure on the rectum; at this time the cervix is fully dilated and the urge to push is great. Restlessness and thrashing about usually begin during the transition phase of the first stage of labor. Complaints of sudden, intense back pain may occur with persistent posterior pressure; however, usually the pain does not have a sudden onset. Asking for medication to relieve pain from the strong contractions usually occurs during the active phase of the first stage of labor.
The nurse teaches a group of clients that nutritional support of natural defense mechanisms indicates the need for a diet high in what nutrient or nutrients? 1. Essential fatty acids 2. Dietary cellulose and fiber 3. Tryptophan, an amino acid 4. Vitamins A, C, E, and selenium
Vitamins A, C, E, and selenium Vitamins A, C, E, and selenium stimulate the immune system. The role of fatty acids in natural defense mechanisms is uncertain. Dietary cellulose and fiber have no known effect on natural defense mechanisms. Tryptophan has no known effect on natural defense mechanisms.
A newborn is circumcised prior to discharge from the hospital. What should the immediate postoperative care include? 1. Keeping the infant NPO for 4 hours to prevent vomiting 2. Encouraging the intake of alkaline fluids to reduce urine acidity 3. Changing the dressing using dry, sterile gauze to maintain cleanliness 4. Encouraging the mother to cuddle her baby to provide emotional support
Encouraging the mother to cuddle her baby to provide emotional support Cuddling is comforting for the mother and baby and provides an opportunity to teach the mother how to take care of the circumcision. There is no contraindication to feeding the infant after the circumcision; nutrition may be withheld before, not after, the procedure. Providing alkaline fluids is inappropriate and could lead to fluid and electrolyte imbalance. Removal of dry gauze will cause bleeding; sterile petrolatum gauze is used and replaced with each diaper change.
While reviewing the result of an intravenous pyelogram, the nurse discovers that the client has a shortened urethra. The client also complains of urinary incontinence. Which nursing intervention is beneficial for the client? 1. Providing thorough perineal care after each voiding 2. Encouraging the client to use the toilet or bedpan every 2 hours 3. Responding quickly to the client’s indication of the need to void 4. Providing privacy, assistance, and voiding stimulants over the perineum
Providing thorough perineal care after each voiding Weakened urinary sphincters and shortened urethras are age-related physiologic changes in older adults. Because a shortened urethra has an increased potential for bladder infections, the nurse should provide thorough perineal care after each voiding. Encouraging the client to use the toilet or bedpan every two hours will help to avoid overflow urinary incontinence. Responding quickly to the client’s indication of the need to void will help to alleviate urinary stress incontinence episodes. Providing privacy, assistance, and voiding stimulants over the perineum will help to initiate voiding in the client.
The nurse is preparing to give grief counseling to a client who lost his or her partner recently. Which intervention does the nurse include as a priority action in the care plan? 1. Giving essential information honestly 2. Inquiring about the client’s spiritual beliefs 3. Knowing the reason why the loss happened in his or her family 4. Providing an environment for the client to express his or her feelings
Providing an environment for the client to express his or her feelings While counseling a grieving client, the nurse first provides an environment for the client to express feelings such as anger, fear, and guilt because this reduces emotional distress in the client. The nurse can give essential information after reducing emotional distress in the client. Inquiring about spiritual beliefs of the client is not a priority nursing intervention while providing grief counseling. The nurse can learn about the reason for the loss after reducing emotional distress in the client.
A nurse is teaching the mother of a toddler with celiac disease the specific foods allowed on the gluten-free diet. What is the most important information for the nurse to help the mother understand? 1. Corn flour is not included in the diet. 2. Labels of prepared foods must be read carefully. 3. Caloric intake is increased to compensate for a deficiency of proteins. 4. The gluten-free diet is discontinued when the affected child starts kindergarten.
Labels of prepared foods must be read carefully. The labels of foods such as gravy, sauces, and other prepared foods must be checked for hidden gluten. Rice and corn are virtually gluten free. Although the diet should be high in calories, it compensates for the lack of carbohydrates (e.g., wheat, rye, barley, and oats), not protein. The diet will be continued at least through adolescence, if not for the child's entire life.
What client behavior indicates to the nurse that a woman needs further teaching regarding breastfeeding her newborn? Correct1 When she leans forward to place her breast in the infant's mouth 2 If she holds the infant level with her breast while in a side-lying position 3 If she touches her nipple to the infant's cheek at the beginning of the feeding Incorrect4 When she puts her finger in the infant's mouth to break the suction after the feeding When the breast is pushed into the infant's mouth, typically the infant's mouth closes too soon, resulting in inadequate latching on. The infant should be brought to the breast rather than the other way around. Holding the infant level with her breast while in a side-lying position facilitates latching on and maintains the infant's head in correct alignment, which promotes sucking and swallowing. Touching the nipple to the infant's cheek at the beginning of the feeding will stimulate the rooting reflex and promote latching on. Putting her finger in the infant's mouth to break the suction after the feeding prevents trauma to the nipple when the infant is removed from the breast.
A client has an above-the-knee amputation of the left leg because of arterial insufficiency. To prevent a hip flexion contracture, in what position should the nurse periodically place this client? 1. Prone position 2. Sitting position 3. Supine position with a pillow under the residual limb 4. Right side-lying position with a pillow between the thighs
Prone position The prone position maintains the hips in extension, which helps to prevent flexion contractures of the hips. The sitting position flexes the hips and knees, which promotes hip and knee flexion contractures. The supine position with a pillow under the residual limb will flex the hip, promoting a hip flexion contracture. In the right side-lying position the left hip will be flexed, which will promote the development of a hip flexion contracture.
A nurse who works in a mental health facility determines that what is the priority nursing intervention for a newly admitted client with bulimia nervosa? 1. Check on the client continually. 2. Observe the client during meals. 3. Teach the client to measure intake and output. 4. Involve the client in developing a daily meal plan.
Check on the client continually. Bulimic clients often hide food or force vomiting; therefore they must be carefully observed. Observing the client during meals is insufficient, because these clients may induce vomiting after eating. Fluid and electrolyte balance can become a problem for these clients, and monitoring is required, but at this time it is the responsibility of the nurse, not the client, to measure intake and output. These clients will not become involved in planning meals; this is a long-term goal.
Before discharging a 9-year-old child who is being treated for acute poststreptococcal glomerulonephritis (APSGN), what information should the nurse plan to give the parents? 1. How to obtain the vital signs daily 2. Date on which to return to prepare for renal dialysis 3. Instructions about which high-sodium foods to avoid 4. List of activities that will encourage the child to remain active
Instructions about which high-sodium foods to avoid Sodium is usually limited to control or prevent edema or hypertension until the child is asymptomatic. The child is usually on a regular diet with sodium restrictions (e.g., salty snacks [potato chips, pretzels, tortilla chips] and hot dogs, bacon, bologna, and other processed meats). It is not necessary to check the vital signs daily, but the healthcare provider may suggest weighing the child daily. Usually recovery from APSGN is complete. The condition does not cause such severe kidney damage that dialysis is necessary. The child should not be kept active, because rest is needed until the child is asymptomatic.
A stationary (nonrolling) walker has been prescribed for a client to aid in ambulation. What should the nurse teach the client to do to use the walker? 1. Place the back legs of the walker about 10 inches (25.4 cm) in front of the feet, shift the body weight to the walker, and step forward. 2. Move the walker about 8 inches (20.3 cm) forward while stepping forward to the walker, with body weight on the walker and both legs. 3.Place the walker flat on the floor with the front legs about 12 inches (30.5 cm) in front of the feet, shift the body weight to the walker, and step forward to take initial steps. 4. Move the walker about 10 inches (25.4 cm) in front of the feet with only the front legs of the walker on the floor, then step forward and put the walker flat.
Place the walker flat on the floor with the front legs about 12 inches (30.5 cm) in front of the feet, shift the body weight to the walker, and step forward to take initial steps. Placing the walker flat on the floor provides stability; putting weight on the walker equalizes weight bearing on the upper and lower extremities. Placing the back legs of the walker about 10 inches (25.4 cm) in front of the feet, shifting the body weight to the walker, and stepping forward places the walker too far in front of the client for safe transfer of body weight; also, all four legs should be flat on the ground. It is not possible to move the walker and have it bear weight at the same time; the walker should be flat on the ground when the client is stepping forward. All four points of the walker should be flat on the ground when the client is stepping forward.
A 4-week-old infant is found to have hypertrophic pyloric stenosis (HPS) and is scheduled for surgery. Oral feedings are usually initiated a few hours after surgery. What does the nurse expect the practitioner to prescribe initially? 1. Electrolyte solution 2. Full-strength formula 3. Half-strength formula 4. Cereal-thickened water
Electrolyte solution After surgery, initial feedings consist of an electrolyte solution such as Pedialyte until the infant’s tolerance of progressive feedings is determined. An increase in feeding osmolarity is attempted after the tolerance of clear liquids is assessed. Thickened cereal is used when an infant experiences gastroesophageal reflux.
One evening an older client with a diagnosis of dementia chokes on a piece of food and becomes panicky and cyanotic. The nurse performs the abdominal thrust maneuver, and a bolus of food pops out of the client’s mouth. After several deep respirations, the client’s cyanosis passes. What is most appropriate for the nurse to do next? 1. Inform the client that everything is fine. 2. Stand the client up while checking the pulse. 3. Touch the client’s hand while providing verbal support. 4. Teach the client how to prevent future similar problems.
Touch the client’s hand while providing verbal support.
A nurse is caring for several school-aged children on the pediatric unit who are on prolonged bed rest and eating regular diets. Which breakfast should the nurse recommend to the children? 1. Oatmeal with raisins and milk 2. Pancakes with sausage and syrup 3. Scrambled eggs with home fries and toast 4. French toast with bacon and cinnamon sugar
Oatmeal with raisins and milk Prolonged immobility can result in constipation and demineralization of bone. Oatmeal and raisins contain roughage, which helps prevent constipation, and milk contains calcium, which is needed for bone strength and growth. Pancakes and French toast each lacks roughage and contains inadequate calcium. Eggs, fries, and toast do not provide needed roughage while on bed rest.
Range-of-motion exercises are prescribed for a child with juvenile idiopathic arthritis. What criterion should the nurse use to evaluate the effectiveness of the exercises? 1. The pain is relieved. 2. The affected joints can flex and extend. 3. The pedal and radial pulses are diminished. 4. The subcutaneous nodules at the joints recede.
The affected joints can flex and extend. The exercises are done to preserve joint function. Exercises do not necessarily relieve pain. Circulation is not affected by the arthritic process. Exercise does not affect the subcutaneous nodules.
A nurse is discussing weight loss with an obese individual with Ménière disease. Which suggestion by the nurse is most important? 1. Limit intake to 900 calories per day. 2. Enroll in an exercise class. 3. Get involved in diversionary activities when there is an urge to eat. 4. Keep a diary of all foods eaten each day.
Keep a diary of all foods eaten each day. Keeping a record of what one eats helps to limit nonconscious and nervous eating by making the individual aware of intake. Limiting calories to 900 per day is a severe restriction that requires a primary healthcare provider’s prescription. Exercise causes rapid head movements, which may precipitate a Ménière attack. Although diversionary activities are a therapeutic intervention, the nurse first should make suggestions that help increase the client’s awareness of personal eating habits.
What is the most appropriate lunch for the nurse to offer a child who is on a restricted-sodium diet? 1. Hamburger on a bun, grapes, lemonade 2. Macaroni and cheese, fresh pears, tomato juice 3. Chicken nuggets, canned baked beans, apple juice 4. Bacon-and-tomato sandwich, chicken noodle soup, low-sodium milk
Hamburger on a bun, grapes, lemonade Fresh fruit and meat are lower in sodium than processed or canned foods and cured meats. Cheese and canned vegetable juices have a high sodium content and should be avoided. Processed chicken and canned beans are high in sodium, as are bacon, bread, and most soups.
A 9-year-old child with cerebral palsy is to be taught the four-point alternate crutch gait. The parents ask why this gait was chosen. How should the nurse respond? 1. "Your child has more power in the arms than in the legs." 2. "Your child doesn't have power or step ability in the legs." 3. "It provides two points of support on the floor between steps." 4. "It provides for equal but partial weight-bearing on each limb."
"It provides for equal but partial weight-bearing on each limb." The four-point alternate crutch gait is a simple and slow but stable gait because there are always three points of support on the floor, with equal but partial weight-bearing on each limb. Telling the parent that their child has more power in the arms than in the legs may or may not be true; the data are insufficient to justify this conclusion. Some power and step ability is required to use the four-point alternate crutch gait. The child has uncoordinated movement in the legs because of the cerebral palsy.
The diet prescribed for a client with diverticulosis includes 30 grams of fiber a day. Which breakfast items should the nurse encourage the client to select? 1. Cream of wheat, milk, and cranberry juice 2. Unstrained orange juice, pancakes, and bacon 3. Oatmeal, sliced bananas, whole wheat toast, and milk 4. Poached eggs on whole wheat toast, tomato juice, and tea
Oatmeal, sliced bananas, whole wheat toast, and milk A breakfast including oatmeal, sliced bananas, whole wheat toast, and milk contains grains and fruit that are high in fiber and helps meet the 30-gram daily requirement of fiber. The other choices do not help meet the 30-gram daily requirements of fiber. Cream of wheat has fiber, but milk and cranberry juice are not high in fiber. Unstrained orange juice, pancakes, and bacon are low-fiber foods. Although whole grain bread is a high-fiber food and tomato juice contains some fiber, this grouping does not have as much fiber as another breakfast choice.
During an 8-hour shift a client drinks two 6-ounce (180 mL) cups of tea and vomits 125 mL of fluid. Intravenous fluids absorbed equaled the urinary output. What is the client’s fluid balance during this 8-hour period? Record your answer using a whole number. ___ mL
235 mL 235 mL is the correct calculation. The client’s intake was 360 mL (12 oz × 30 mL = 360 mL) and the loss was 125 mL of fluid; 360 mL – 125 mL = 235 mL.
A client who has intermittently been having painful, swollen knee and wrist joints during the past 3 months is diagnosed with rheumatoid arthritis. What type of diet should the nurse expect the primary healthcare provider to prescribe? 1. Salt-free, low-fiber diet 2. High-calorie, low-cholesterol diet 3. High-protein diet with minimal calcium 4. Regular diet with vitamins and minerals
Regular diet with vitamins and minerals There are no dietary restrictions, but iron and vitamins should be encouraged to treat any underlying nutritional deficiencies. A salt-free, low-fiber diet is not indicated. A high-calorie diet will increase the client’s weight; this is contraindicated because it will increase the strain on weight-bearing joints. A balanced diet should fulfill nutritional needs; there is no need to increase protein or restrict calcium.
The nurse is teaching the parents of a toddler-age client who is prescribed iron supplements for iron-deficiency anemia. Which food should the nurse encourage the parents to provide to enhance absorption of iron? 1. Cereal 2. Spinach 3. Whole milk 4. Orange juice
Orange juice Iron absorption is enhanced in an acidic environment; therefore, the nurse would suggest that the parents provide the iron supplement with orange juice which is high is ascorbic acid (vitamin C). Phytates, which are found in cereal, decrease the absorption of iron. Oxalates, found in spinach and whole milk, also decrease the absorption of iron and should be avoided.
A client has chronic obstructive pulmonary disease (COPD) and cor pulmonale. When teaching about nutrition, what does the nurse instruct the client? 1. Eat small meals six times a day to limit oxygen needs. 2. Drink large amounts of fluid to help liquefy secretions. 3. Lie down after eating to conserve energy needed for digestion. 4. Increase the intake of protein to decrease intravascular hydrostatic pressure.
Eat small meals six times a day to limit oxygen needs. Eating small meals will decrease the amount of oxygen necessary for ingestion and digestion at any one time; a small volume of food in the stomach will not impede the downward movement of the diaphragm during inhalation. Although fluids can help liquefy secretions, they should not be encouraged for a client with heart failure. Lying down increases intraabdominal pressure, pushing a full stomach against the diaphragm and limiting respiratory excursion. Protein maintains or increases hydrostatic pressure; it does not decrease it.
While a client is being interviewed on her first prenatal visit she states that she has a 4-year-old son who was born at 41 weeks' gestation and a 3-year-old daughter who was born at 35 weeks' gestation. The client lost one pregnancy at 9 weeks and another at 18 weeks. Using the GTPAL system, how would you record this information? 1. G5 T1 P1 A2 L2 2. G4 T1 P1 A2 L2 3. G4 T2 P0 A0 L2 4. G5 T2 P1 A1 L2
G5 T1 P1 A2 L2 The client is gravida (G) 5: the current pregnancy, the 41-week pregnancy, the 35-week pregnancy, the 9-week pregnancy, and the 18-week pregnancy. She has had one term (T) pregnancy (one that lasts 40 weeks plus or minus 2 weeks): the 41-week pregnancy. The 35-week pregnancy is considered preterm (P). Pregnancies that end before 20 weeks are considered abortions, so the losses at 9 and 18 weeks would be scored as A2. The other options do not consider the present pregnancy or the correct definitions of term and preterm or do not include the abortions.
A 7-year-old child with juvenile idiopathic arthritis has difficulty getting ready for school in the morning because of joint pain and stiffness. Which recommendation should the nurse make to the family? 1. Administer acetaminophen before bedtime. 2. Ice the joints that are painful in the evening. 3. Encourage a program of active exercise after awakening. 4. Provide warm, moist heat to the affected joints before arising.
Provide warm, moist heat to the affected joints before arising. Warm, moist heat will reduce inflammation and pain and thus promote mobility. Acetaminophen administered at night will not decrease pain the following morning. Ice will not be beneficial, regardless of when it is administered. Gentle stretching, not active exercise, should be employed.
A parent tells the nurse that she is concerned about her 8-month-old baby's diet because the infant will eat only mashed potatoes and drink only milk. The nurse anticipates that this diet will result in a deficiency of which nutrient? 1. Iron 2. Vitamins 3. Potassium 4. Amino acids
Iron Potatoes and whole milk are not adequate sources of iron; by the time a child is 8 months of age, fetal iron stores are depleted and exogenous iron sources are needed. Milk contains vitamins A, C, and D. Potatoes are a rich source of potassium. There are amino acids in milk because it is an animal protein.
A 9-year-old child who has successfully completed the emergency (resuscitative) phase of treatment for a severe burn injury is started on a high-protein, high-calorie diet. Which snacks should the nurse encourage between meals? Select all that apply. 1. Crackers and cheese 2. White bread and honey 3. Orange juice and cookies 4. Banana pudding and whipped cream 5. Frozen yogurt and chocolate sprinkles
Crackers and cheese Banana pudding and whipped cream Frozen yogurt and chocolate sprinkles The cheese increases protein intake, which is needed for tissue repair, and the crackers contain carbohydrates that provide calories for the increased metabolism. The milk in the pudding contains protein, and whipped cream contains fat. The banana is high in potassium. All of these nutrients are essential for tissue repair. Frozen yogurt contains both protein and calories. Although bread and honey increase caloric intake, they furnish little of the protein needed for tissue repair. Although orange juice and cookies increase vitamin and fluid intake, they do not supply protein.
During discharge teaching, a client with an ileal conduit asks how frequently the urine pouch should be emptied. Which reply by the nurse is best? 1. "To prevent leakage and pulling of the pouch from the skin, it should be emptied every few hours." 2. "To prevent skin irritation, it should be emptied every hour if any urine has collected in the bag." 3. "To reduce the risk of infection, the system should be opened as little as possible; two times a day is adequate." 4. "To reduce the cost of drainage pouches, it should be emptied once the system is switched to a bedside collection bag."
"To prevent leakage and pulling of the pouch from the skin, it should be emptied every few hours." The weight of a full bag can pull the appliance from the skin and cause leakage; it should be emptied approximately every 2 to 3 hours or when half full. Emptying the collection bag every hour is too often; it should be emptied when it is half full. With proper technique, draining the pouch should not put the individual at risk for infection. The collection bag would be too full if emptied only twice a day. A drainage pouch will always be in place with an ileal conduit [1] [2] and urine emptied every few hours.
A 4-year-old child is found to have Hirschsprung disease (aganglionic megacolon), and the healthcare provider prescribes a special diet. The nurse is assigned to provide dietary instructions for the parents. What diet will the nurse be teaching the parents? 1. High-fat 2. High-fiber 3. Low-calorie 4. Low-residue
Low-residue A low-residue diet is important to prevent the development of bulk, which will further irritate the colon. There are no recommended changes in the amount of fat in the diet. A high-fiber diet is contraindicated because it may cause an obstruction. To maintain or improve the child's nutritional status, calories should not be restricted.
The postoperative diet prescription for a client who had a colostomy states, "Diet as tolerated." Which principle should the nurse include in the teaching plan to help guide the client with food choices? 1. Specific foods will cause most clients the same discomfort. 2. A low-residue diet should be followed to avoid overstimulating the intestine. 3. More rigid dietary rules limiting food choices are needed to provide security. 4. A return to a regular diet as soon as possible promotes physical rehabilitation.
A return to a regular diet as soon as possible promotes physical rehabilitation. A regular diet is recommended after a colostomy because individuals will discover their own food intolerances. Each individual reacts differently to foods. A low-residue diet is not necessary; once healing occurs, a diet with adequate residue promotes peristalsis and colostomy functioning. Rigid dietary regulations usually increase anxiety and are not needed; return to previously tolerated foods provides security.
The nurse provides moist heat to a client with cartilage degeneration. What is the rationale for this nursing intervention? 1. To slow bone loss 2. To prevent skin breakdown 3. To increase muscle strength 4. To increase blood flow to the area
To increase blood flow to the area Cartilage degeneration is a physiologic change of the musculoskeletal system that can be treated by providing moist heat, which increases blood flow to the area. Weight-bearing exercises are taught to slow bone loss. The client is instructed to prevent pressure on the bony prominences to prevent skin breakdown. The client is taught isometric exercises to increase muscle strength.
A client is diagnosed with chronic pancreatitis. Which dietary instruction is most important for the nurse to share with the client? 1 Eat a low-fat, low-protein diet 2 Avoid foods high in carbohydrates Correct3 Avoid ingesting alcoholic beverages Incorrect4 Eat a bland diet with no snacks in between Alcohol will cause the most damage. Alcohol increases pancreatic secretions, which cause autodigestion of the pancreas, leading to severe pain. Although the diet should be low in fat, it should be high in protein; also, it should be moderate in carbohydrates. The client should be consuming a sufficient amount of complex carbohydrates each day to maintain weight and promote tissue repair. A bland diet can be consumed, but snacks high in calories are also recommended.
The nurse is caring for a pregnant client during a contraction stress test (CST). In what position should the nurse place the client? 1 Sims position to facilitate examination Correct2 Semi-Fowler position to avoid hypotension 3 Lithotomy position to enhance visualization 4 Trendelenburg position to prevent cervical pressure The semi-Fowler position prevents supine hypotension and is recommended for both safety and comfort. The Sims position makes monitoring difficult. The lithotomy position is contraindicated for a CST because a vaginal examination is not necessary. The Trendelenburg position is used for shock or a prolapsed cord, not for a CST.
A 1-year-old infant with a distended abdomen is admitted to the pediatric unit with the diagnosis of Hirschsprung disease. In which position should the nurse place the infant? 1 Prone 2 Sitting 3 Supine Correct4 Lateral In the lateral position the distended abdomen does not press against the diaphragm, facilitating lung expansion. The prone position is difficult to assume with a distended abdomen; also, the weight of the body will limit lung expansion. The sitting position is not conducive to easy breathing and is difficult to assume with abdominal distention. The distended abdomen will press against the thighs and then the diaphragm, which will hinder full lung expansion. The supine position will interfere with respiration because the abdominal distention will exert pressure against the diaphragm.
A strict vegetarian (vegan) becomes pregnant and asks the nurse whether there is anything special she should do in regard to her diet during pregnancy. What is the most important measure for the nurse to instruct the client to take? 1 Eat at least 40 g/day of protein. 2 Drink at least 1 quart/day of milk. 3 Take a vitamin supplemented with iron every day. Correct4 Plan to eat from specific groups of vegetable proteins each day. A variety of incomplete proteins (vegetable proteins) can be combined to provide all of the essential amino acids. The pregnant client should eat at least 71 g/day of protein. Vegans do not drink milk. Taking a vitamin supplemented with iron each day is not the most important factor in diet planning; other nutrients also must be provided.
A nurse gives a nasogastric feeding to a preterm male infant. As the mother watches, she asks, "Would it hurt my baby to suck on a pacifier during the feeding?" How should the nurse best respond? 1 "It's difficult to determine the color of his lips while he's sucking on a pacifier. We'd rather wait until he's a little older." 2 "If you want, he can suck on a pacifier now, but he may have problems later when he starts to suck from the breast or bottle." Correct3 "Sucking on a pacifier during tube feedings may help him associate sucking with food so that he'll adjust better to oral feedings." 4 "There's no real benefit in using a pacifier. Also, there's a relationship between using a pacifier and the development of buck teeth." The pacifier may satisfy nonnutritive sucking needs and stimulate flow of saliva and digestive juices. Protruding ("buck") teeth are associated with thumb sucking. Sucking on a pacifier promotes adaptation later to the breast or bottle; it does not hamper it. There is no evidence that a preterm infant's care is jeopardized by nonnutritive sucking.
A client is receiving a 2-gram sodium diet. The family members ask whether they can bring snacks from home. Which food item will the nurse suggest? 1 Ice cream 2 Cheese sticks Correct3 Fresh orange wedges 4 Peanut butter cookies An orange contains only trace amounts of sodium. Dairy products such as ice cream and cheese are high in sodium and should be avoided. Peanut butter cookies are high sodium.
The nurse observes that a client has insomnia. Which intervention included in the care plan indicates a priority nursing intervention? 1 Teaching about medication administration procedures Correct2 Teaching the client about sleep and cognitive changes 3 Teaching about dietary measures to be followed at night Incorrect4 Teaching about nonpharmacologic measures including sleep techniques The nurse should first teach about sleep and cognitive changes to the client with insomnia. The nurse can teach about medication administration procedures, but this is not the priority. The nurse can teach dietary measures to be followed at night after teaching about sleep and behavioral changes. Teaching about nonpharmacologic procedures is also not the priority nursing intervention.
A nurse in a rehabilitation center teaches clients with quadriplegia to use an adaptive wheelchair. Why is it important that the nurse provide this instruction? Correct1 It is unlikely that the client will regain the ability to walk. 2 It prepares them for wearing braces. 3 It assists them in overcoming orthostatic hypotension. 4 They have the strength in the upper extremities for self-transfer. Clients with quadriplegia do not have the muscle innervation, strength, or balance needed for ambulation. Bracing and crutch-walking require muscle strength and coordination that an individual with quadriplegia does not have. Orthostatic hypotension can be prevented by a gradual assumption of the upright position and does not necessarily require a wheelchair. Quadriplegia refers to paralysis of all four extremities.
A nurse develops a teaching plan for a client with rheumatoid arthritis. What should the nurse include in the plan about ways to reduce joint stress? Correct1 "If experiencing pain after 1 to 2 hours of activity, actively take measures to address the pain." 2 "When performing day-to-day tasks, use smaller muscles more frequently than large muscles." 3 " Schedule all of the heavy tasks at one time, and then schedule a long rest period." 4 "When the joints are swollen, an increase in exercise will help reduce swelling." Addressing and managing joint pain protects the joints, especially if the pain lasts more than 1 or 2 hours after a particular activity. The client should use large muscles, such as pushing doors open with arms rather than fingers. Doing heavy tasks at one time will increase joint stress; heavy and light tasks should be alternated. When the inflammatory process is active, the joint should be at rest as much as possible.
Which statement made by a diabetic client shows that dietary teaching by the nurse was effective? Incorrect1 "My diet should be rigidly controlled to avoid emergencies." Correct2 "My diet can be planned around a wide variety of commonly used foods." 3 "My diet is based on nutritional requirements that are the same for all people." 4 "My diet must not include eating any combination dishes and processed foods." Each client should be given an individually devised diet consisting of commonly used foods from the American Diabetic Association (Canadian Diabetes Association) diet; family members should be included in the diet teaching. Rigid diets are difficult to follow; appropriate substitutions are permitted. Nutritional requirements are different for each individual and depend on many factors, such as activity level, degree of compliance, and physical status. Combination dishes and processed foods can be eaten when accounted for in the dietary regimen.
What should a nurse include in nutritional planning for a newly pregnant woman of average height who weighs 145 lb (65.8 kg)? 1 A decrease of 100 calories per day 2 A decrease of 200 calories per day Correct3 An increase of 300 calories per day 4 An increase of 500 calories per day An increase of 300 calories per day is the recommended caloric increase for adult women to meet the increased metabolic demands of pregnancy. A decrease of 100 to 200 calories per day will not meet the metabolic demands of pregnancy and may harm the fetus. An increase of 500 calories per day is the recommended caloric increase for breastfeeding mothers.
A nurse who has agreed to serve as camp nurse for a week has an influx of children with abdominal pain late in the week. The nurse encourages the camp cook to increase the amounts of fruits and vegetables, whole grains, and other high-fiber foods in the meals. The nurse knows that this will help decrease the incidence of abdominal pain caused by which symptom? 1 Hunger 2 Vomiting 3 Appendicitis Correct4 Constipation Children at camp tend to withhold stool because of a lack of privacy and embarrassment; they may then become constipated and experience abdominal pain. Hunger, vomiting, and appendicitis are not common occurrences at camp.
A nurse is assessing a client with a diagnosis of primary insomnia. Which findings from the client's history may be the cause of this disorder? Select all that apply. Correct1 Significant life stress 2 Severe anxiety 3 Generalized pain Correct4 Excessive caffeine 5 Chronic depression Correct6 Environmental noise/distractors Acute or primary insomnia [1] [2] is caused by emotional or physical stress not related to the direct physiologic effects of a substance or illness. Excessive caffeine intake can cause disruptive sleep hygiene; caffeine is a stimulant that inhibits sleep. Environmental noise causes physical and emotional discomfort and is therefore related to primary insomnia. Severe anxiety is usually related to a psychiatric disorder and therefore causes secondary insomnia. Generalized pain is usually related to a medical or neurologic problem and therefore causes secondary insomnia. Chronic depression is usually related to a psychiatric disorder and therefore causes secondary insomnia.
What liquid should a nurse recommend that a parent offer an 8-month-old infant who has diarrhea? Correct1 Formula 2 Skim milk 3 Ginger ale 4 Orange sports drink Formula or breast milk is recommended because it supplies most of the nutrients that older infants require and promotes hydration. Cow's milk should not be offered to infants because their gastrointestinal systems are not mature enough to tolerate its nutrient components. High-carbohydrate fluids such as ginger ale and sports drinks are contraindicated because they are hypertonic and will aggravate diarrhea.
A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention? 1 Administering an antiviral agent Correct2 Clustering care to conserve energy 3 Offering oral fluids to promote hydration 4 Providing an antitussive agent whenever necessary Often the infant will have a decreased pulmonary reserve, and the clustering of care is essential to provide for periods of rest. Antiviral therapy is controversial for this age group and is not given unless complications ensue. Intravenous fluids are given during the acute phase to prevent dehydration. Antitussive agents are not used; nasal secretions are aspirated with the use of a bulb syringe whenever necessary.
Correct1 Asking the client what she usually eats at each meal 2 Explaining to the client why spicy foods should be avoided 3 Instructing the client to add calories while continuing to eat a healthy diet 4 Providing the client with a list of foods for reference when planning meals Successful dietary teaching should incorporate the client's food preferences and dietary patterns. Spicy foods are permissible if the client does not experience discomfort after eating them. Instructing the client to add calories while continuing to eat a healthy diet presupposes that the client has been eating a healthy diet. It does not provide for the additional protein requirements of pregnancy. Providing the client with a list of foods for reference when planning meals does not take into consideration the client's likes and dislikes or cultural preferences.
Which dietary instruction would be most beneficial to a client who has undergone a hypophysectomy and has difficulty passing stools? Correct1 "Drink plenty of water." 2 "Eat foods rich in protein." 3 "Drink a glass of milk daily." 4 "Eat foods rich in carbohydrates." The client should be instructed to drink plenty of water (roughly 8 to 10 glasses a day) to relieve constipation. Although proteins are required for overall health, proteins will not relieve constipation. Milk may cause constipation in certain individuals. Carbohydrates act as power sources; they do not relieve constipation.
Twelve hours after sustaining full-thickness burns to the chest and thighs a client who is on nothing-by-mouth status (NPO) is reporting severe thirst. The client’s urinary output has been 60 mL/hr for the past 10 hours. No bowel sounds are heard. What should the nurse do? 1 Give the client orange juice by mouth. 2 Increase the client’s intravenous (IV) flow rate. Correct3 Moisten the client’s lips with a wet 4 × 4 gauze. 4 Offer the client 4 oz (120 mL) of water by mouth. No bowel sounds are present; therefore, the client must remain NPO. Comfort measures may be helpful until bowel sounds return and the primary healthcare provider changes the dietary prescription. Giving the client orange juice or offering 4 oz (120 mL) of water by mouth is unsafe; the client must be kept NPO until bowel sounds are present. The urinary output is adequate; there is no need to increase IV fluids. Also, the nurse cannot increase the IV flow rate without a primary healthcare provider’s prescription.
What should the nurse teach parents about their newborn's diagnosis of phenylketonuria (PKU)? Correct1 A low-phenylalanine diet is required. 2 Phenylalanine is not necessary for growth. 3 Phenylalanine can be administered to correct the deficiency. 4 A substitute for phenylalanine is an increased amount of other amino acids. Reducing dietary phenylalanine helps prevent brain damage. The PKU diet is planned to maintain the serum phenylalanine level at 2 to 8 mg/100 mL. Phenylalanine is essential for growth and development of the brain. Administering phenylalanine is contraindicated. There is no substitute for phenylalanine, which is one of the essential amino acids.
During the admissions process, the nurse initially assesses the patient’s radial pulse primarily for what purpose? Your Answer: B Establishment of a baseline as part of the patient’s vital signs
What will the nurse instruct nursing assistive personal (NAP) to do when measuring an adult patient’s radial pulse? Your Answer: D Palpate the patient’s inner wrist on the thumb side with the fingertips of your two middle fingers.
What is the nurse’s priority action if a patient’s radial pulse has an irregular rhythm? Your Answer: B Assess the patient for a pulse deficit.
Inadequate oxygenation to the body will cause the radial pulse to become: Your Answer: A Tachycardic
Which action would best assess the effect of exercise on a patient’s radial pulse measurement? Your Answer: A Measuring the patient’s radial pulse before and after exercise.
Which action can the nurse take to keep a patient from consciously controlling his or her breathing during an assessment? Your Answer: B Assess respiration after measuring the pulse.
On the last assessment of a patient’s respiration, her respiratory rate was 10 breaths per minute. What should the nurse do when conducting the next assessment of this patient’s respiratory rate? Your Answer: D Count breaths for 60 seconds.
When measuring a patient’s respiratory rate, the nurse will count the number of completed respiratory cycles per minute. What is the definition of a respiratory cycle? Your Answer: A The number of inspirations and expirations per minute.
During the assessment of a patient’s respiratory rate, when the second hand reaches the 15-second mark, the respiratory count is 8. What should the nurse do at this time? Your Answer: D Continue to count the patient’s breaths for a full 60 seconds.
The nurse plans to assess a patient’s respiratory rate; however, the patient has just returned from ambulating to the bathroom. What should the nurse do to minimize the effect of exercise on the patient’s respiratory rate? Your Answer: C Encourage the patient to rest for 10 minutes before assessing respiration. |
When the family of a client who has a 2 gram sodium diet asks whether they can bring snacks from home which food item will the nurse suggest?
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