Adaptive Quiz 3
A 5-year-old child in renal failure who has undergone creation of an arteriovenous fistula access begins hemodialysis three times a week. The nurse teaches the mother the specific care her child needs. What statement indicates that further teaching is necessary?
"It's OK to take his blood pressure on the arm with the fistula."
A client has a permanent sigmoid colostomy, and colostomy irrigations are prescribed. The client asks the nurse why they are needed. How should the nurse respond?
"They help establish an elimination schedule."
A nurse is caring for a client who just had a gastrectomy. What should the nurse emphasize when teaching the client how to avoid dumping syndrome?
Eat small meals with low carbohydrate and moderate fat content
The nurse is caring for a client who is on a low-carbohydrate diet. With this diet, there is decreased glucose available for energy and fat is metabolized for energy, resulting in an increased production of which substance in the urine?
Ketones
A client scheduled for a transurethral prostatectomy expresses concern about the effect the surgery will have on sexual ability. Which information should the nurse share with the client?
May experience retrograde ejaculations
A nurse in the pediatric clinic is planning care for a 7-year-old boy with enuresis. What is an appropriate short-term goal for this child?
The interval between voidings will increase by 1 hour.
After assessing a client with an involuntary loss of urine, the nurse suspects overflow incontinence. Which symptom supports the nurse's suspicion?
Constant dribbling of urine
A client with myasthenia gravis has increased difficulty swallowing. Which action will the nurse take to prevent the aspiration of food?
Schedule meals with the peak effect of an anticholinesterase muscle stimulant.
A nurse evaluates a client's understanding regarding oral contraceptives and concludes teaching is successful when the client states, "While I'm taking birth control pills I should increase my intake of foods containing" what nutrient?
Folic Acid
A nurse provides dietary teaching about a low-sodium diet for a client with hypertension. Which nutrient selected by the client indicates a correct understanding about foods that are low in natural sodium?
Fruits
An older client's colonoscopy reveals the presence of extensive diverticulosis. Which type of diet should the nurse encourage the client to follow?
High-fiber
A nurse is discussing diet with a pregnant client who is 5 feet 4 inches tall (163 cm) and whose pre-pregnancy weight was 120 lb (54 kg). What should the nurse include about the changes in calories and nutrients, compared with the pre-pregnancy diet, during the second trimester?
Increasing total daily caloric intake by 340 calories
After a subtotal gastrectomy (Billroth I), a client begins to eat more food in varied forms. After meals, the client experiences a cramping discomfort, a rapid pulse, and waves of weakness, which often are followed by nausea and vomiting. What does the nurse conclude is the cause of this response?
Quick passage of hyperosmolar food solution into the small intestine
A school nurse informs the mother of an 11-year-old girl that her daughter has been giving her lunch to friends and buying cookies and cola at lunchtime. The mother asks the nurse how best to solve this problem. How should the nurse respond?
"Have her help you plan nutritious meals that include her favorite foods."
A nurse is caring for a client with a new colostomy. Which client outcome is most important for achievement of long-range goals associated with adjusting to a new colostomy?
Readiness to accept an altered body function
After assessing a 2-year-old child, the nurse concludes that the child lacks physical readiness for toilet training. Which assessment finding supports the nurse's conclusion?
The child stays dry for 1 hour during the day.
A nurse is caring for a client after surgical creation of a conduit diversion (ileal conduit). Which information will the nurse consider when planning care for this client?
Urine continuously drains from it.
Which prenatal teaching is most applicable for a client who is between 13 and 24 weeks' gestation?
Growth of the fetus, personal hygiene, and nutritional guidance
A client is diagnosed as having the hepatitis B virus (HBV). The nurse reviews the client's health history for possible situations in which exposure may have occurred. Which event does the nurse determine is most likely the source of this infection?
Had a small tattoo on the arm three months ago
A client with the diagnosis of schizophrenia refuses to eat meals. Which nursing action is most beneficial for this client?
Having a staff member sit with the client in a quiet area during mealtimes