Final foundations

The nurse knows that spatial behavior is related to territoriality in many Latino cultures. Which client needs are associated with territoriality? Select all that apply. 1. Utility 2. Privacy 3. Security 4. Autonomy 5. Self-identity 6. Philosophy

2,3,4,5

A client underwent creation of an ileostomy 2 days ago. The nurse checks the client for signs of which acid-base disorder that a client with an ileostomy is at risk for developing?

metabolic acidosis

someone with iron deficiency anemia should eat what foods

red meat liver organ meats oysters whole wheat bread egg yolk spinach kale beet greens carrots raisins

A hospitalized client is a lacto-vegetarian. Which food item should the nurse remove from the meal tray? 1. Eggs 2. Milk 3. Cheese 4. Broccoli

1

A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet? 1. Baked turkey 2. Tomato soup 3. Boiled shrimp 4. Chicken gumbo

1

The nurse is caring for a new immigrant from the Philippines who is in labor. The client is 4 cm dilated and 30% effaced. This is her first child. The mother is grimacing. Her pulse, respiratory rate, and blood pressure are elevated. The nurse offers to check on a prescription for an epidural. The mother declines. The nurse hypothesizes the client may be declining the epidural for which reasons? Select all that apply. 1. Filipino mothers fear drug addiction. 2. Filipino mothers decrease their pain through a verbal release. 3. Filipino mothers prefer to accept treatments for pain from their parteras. 4. Filipino mothers are often stoic and view childbirth pain as a normal part of life. 5. Filipino mothers believe pain is a form of spiritual atonement for one's past deeds.

1,5

A 24-year-old Chinese-American who delivered her baby yesterday is breastfeeding her infant girl. The client's mother asked the nurse not to include cold foods on her daughter's tray because they are not good for the baby. The nurse responds by telling the client that she can have what she wants; it is not up to her mother. This response of the nurse demonstrates which cultural characteristic? 1. Subculture 2. Assimilation 3. Ethnocentrism 4. Cultural relativism

3

A newly pregnant client is asking how to prevent neural-tube birth defects. The nurse reinforces which food choices to include in the diet? Select all that apply. 1. Milk 2. Peanuts 3. Oranges 4. Broccoli 5. Egg yolks 6. Grapefruit

3,4,6

A client has been diagnosed with pernicious anemia. In planning care for the client, the nurse anticipates that the client will be treated with which vitamin or mineral? 1. Iron 2. Folic acid 3. Thiamine 4. Vitamin B12

4

The nurse determines that which herbal therapies can be prescribed for use as an antispasmodic? Select all that apply. 1. Aloe 2. Kava 3. Ginger 4. Chamomile 5. Peppermint oil

4, 5

The nurse is reinforcing instructions to a client on how to decrease the intake of potassium in the diet. The nurse determines the need for further teaching if the client selects which foods to include in the diet? Select all that apply. 1. Eggs 2. Bread 3. Lettuce 4. Potatoes 5. Avocados 6. Salt substitute

4,5,6

The nurse is assigned to assist in caring for a client who is receiving parenteral nutrition with fat emulsion. The nurse is instructed to monitor the client for signs of fat overload. The nurse monitors for which signs and symptoms of this complication?

Fever leukocytosis hyperlipidemia prussic urticaria focal seizures

The licensed practical nurse (LPN) is assisting in the care of a client who overdosed on acetylsalicylic acid 24 hours ago. The LPN should report to the registered nurse (RN) which findings associated with an anticipated acid-base disturbance?

drowsiness headache tachypnea

foods to avoid when diagnosis of hyperphosphatemia

fish chicken eggs milk products vegetables whole grains carbonated beverages

A client is having problems with blood clotting. Which food item should the nurse encourage the client to eat?

green, leafy vegetables

signs and symptoms of respiratory alkalosis

tachypnea changes in mental status dizziness pallor round the mouth spasms of muscles of hands hypokalemia hypocalcemia

The nurse is providing dietary instructions to a client with gout. The nurse should tell the client to avoid which food item? 1. Scallops 2. Chocolate 3. Cornbread 4. Macaroni products

1

The nurse is reinforcing discharge instructions to a Chinese client regarding prescribed dietary modifications. During the teaching session, the client continually turns away from the nurse. Which nursing action is most appropriate? 1. Continue with the instructions, verifying client understanding. 2. Walk around the client so that the nurse continually faces the client. 3. Identify the importance of the instructions for the maintenance of health care. 4. Give the client a dietary booklet and return later to continue with the instructions.

1

The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse should tell the client to select which food item that is high in riboflavin? 1. Milk 2. Tomatoes 3. Citrus fruits 4. Green, leafy vegetables

1

The nurse is caring for a Southeast Asian woman who presented to the emergency department with complaints of a headache and nausea. The client is accompanied by her adult son. Upon examination, the nurse notes long pale red welts on both arms. Which actions should the nurse take next? Select all that apply. 1. Ask if she has used any home remedies. 2. Assess cultural health beliefs and practices. 3. Report the use of coin rubbing to social services. 4. Remove the adult son from the room immediately. 5. Recognize the redness is a result of a traditional form of healing.

1,2,5

The nurse reinforces instructions regarding diet for a client at risk for hypokalemia. The nurse determines there is a need for further teaching when the client selects which foods as sources high in potassium? Select all that apply. 1. Bread and butter 2. Carrots and peas 3. Peppers and onions 4. Beef and potato salad 5. Avocados and mushrooms

1,2,3

The nurse is asked to assist with preparing a client who will be receiving a continuous total parenteral nutrition (TPN) solution via a central line. The nurse plans to institute which interventions for this client related to the TPN? Select all that apply. 1. Central line dressing changes per protocol 2. Blood glucose monitoring around the clock 3. Monitoring central venous pressure every shift 4. Using an electronic infusion pump with the infusion 5. Applying sequential compression devices (SCD) to the legs 6. Reviewing prescribed blood laboratory values including electrolytes

1,2,4,6

The nurse is reinforcing instructions to a client regarding how to decrease the intake of phosphorus in the diet. The nurse should tell the client that which food items are allowed with few restrictions in a phosphorus-restricted diet? Select all that apply. 1. Fish 2. Apples 3. Almonds 4. White bread 5. Egg whites 6. Whole-grain pasta

2,4,5

The nurse is caring for an older Orthodox Jewish client whose condition is terminal. The nurse is implementing a plan of care and wishes to communicate this plan with the family and client. The nurse should be aware of which end-of-life religious practices when planning and communicating with the client and family? Select all that apply. 1. The client may demonstrate a high level of anxiety. 2. Religious laws are suspended during times of severe illness. 3. During the process of dying, visitors and conversation should be kept to a minimum. 4. Clients that are of the Orthodox Jewish faith are usually very quiet and do not verbalize pain. 5. If the client dies, care is given so that the body is not be touched by a person of the opposite sex.

1,2,5

The nurse is caring for a Jewish client who follows a kosher diet. Which foods should the nurse use in planning meals for the client? Select all that apply. 1. Tuna 2. Pork 3. Chicken 4. Potatoes 5. Apples

1,3,4,5

The nurse needs to increase the calcium in the diet of a client who is lactose intolerant. Which food items should the nurse encourage? Select all that apply. 1. Milk 2. Tofu 3. Cheese 4. Broccoli 5. Sardines 6. Mustard greens

2,4,5,6

The nurse caring for a client with a neurological disorder is assisting in planning care to maintain nutritional status. The client has had a swallowing study done that shows the client is at risk for aspiration and is able to feed self. The nurse should review which interventions with the unlicensed assistive personnel (UAP)? Select all that apply. 1. Add the prescribed thickener to liquids. 2. Have the client sitting up at 45 degrees. 3. Follow each swallow of food with a sip of water. 4. Observe client for episodes of coughing or choking. 5. Take the client for a walk before the meal to provide stimulation.

1,4

The nurse is caring for an elderly Hispanic client who is a migrant farm worker and has been admitted for asthma. The nurse is unfamiliar with the cultural practices and beliefs of the client's home land. Which questions are appropriate for the nurse to ask when caring for this client? Select all that apply. 1. What do you believe is causing your illness? 2. Why don't you take some asthma medication? 3. Why do you wear that amulet around your neck? 4. Are there any remedies you have used in the past? 5. Who do you usually see for help when you are sick?

1,4,5

The nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat hypertension. The nurse determines that there is a need for further teaching when the client makes which statement? 1. "This diet will help lower my blood pressure." 2. "Fresh foods such as fruits and vegetables are high in sodium." 3. "This diet is not a replacement for my antihypertensive medications." 4. "The reason I need to lower my salt intake is to reduce fluid retention."

2

The nurse reinforces dietary instructions to a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines the client has understood if the client plans to include which foods in the diet? Select all that apply. 1. Apples 2. Raisins 3. Kiwifruit 4. Bananas 5. Pineapple 6. Canned peaches

2,3,4

The nurse has given dietary instructions to a client to minimize the risk of osteoporosis. The nurse determines that the client understands the recommended changes if the client verbalizes the intention to increase intake of which foods? Select all that apply. 1. Fish 2. Yogurt 3. Potatoes 4. Chicken 5. White bread 6. Cottage cheese

2,6

The nurse is assisting in preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that surgery is necessary. Considering the client's religious preferences, the nurse should first verify with the client and then document which information? 1. Faith healing is primarily practiced. 2. Medication administration is not allowed. 3. Surgery is prohibited in this religious group. 4. The administration of blood and blood products is forbidden.

4

The nurse is providing care to a client diagnosed with multiple sclerosis. The nurse knows that which populations are affected by this disease? Select all that apply. 1. Multiple sclerosis affects women twice as often as men. 2. Native-Americans are always immune from this disease. 3. Adults who live in colder climates never acquire this condition. 4. People who had a traumatic back injury are more likely to be affected. 5. Multiple sclerosis occurs in adults between the ages of 20 and 50 years. 6. Multiple sclerosis most often affects Caucasians of Northern European ancestry.

1,5,6

When reinforcing dietary instructions to a client with irritable bowel syndrome whose primary symptom is alternating constipation and diarrhea, the nurse should tell the client that which foods are best to include in the diet for this disorder? Select all that apply. 1. Beans 2. Apples 3. Cabbage 4. Brussels sprouts 5. Whole-grain bread

2,5

The nurse is preparing to deliver a food tray to a client whose religion is Judaism and follows Kosher preferences. The nurse checks the food on the tray and notes that the client has received a roast beef dinner with whole milk as a beverage. Which action should the nurse take? 1. Deliver the food tray to the client. 2. Replace the whole milk with fat-free milk. 3. Ask the dietary department to replace the roast beef with pork. 4. Call the dietary department and ask for a new meal tray without the milk.

4

A client receiving total parenteral nutrition (TPN) asks the nurse if he has developed diabetes when the capillary blood glucose level is monitored and he is given insulin. The nurse explains that which is the reason for monitoring glucose levels and administering insulin? 1. TPN impairs pancreatic function and insulin production. 2. TPN increases the cortisol levels, which causes hyperglycemia. 3. TPN increases the risk for infection, which raises the blood glucose. 4. TPN contains concentrated carbohydrates and raises blood glucose.

4

The nurse is caring for a group of clients who are taking herbal medications at home. Which client should be given instructions with regard to avoiding the use of herbal medications? 1.A 60-year-old male client with rhinitis 2. A 24-year-old male client with a lower back injury 3. A 10-year-old female client with a urinary tract infection 4. A 45-year-old female client with a history of migraine headaches

3