A client with oxylate renal calculi should be taught to limit his intake of foods such as:
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Solution
Answer A is correct. The client with oxylate renal calculi should limit sources of oxylate, which include strawberries, rhubarb, and spinach. Answers B, C, and D are incorrect because they are not sources of oxylate.
Following a generalized seizure, the nurse can expect the client to:
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Solution
Answer B is correct. Following a generalized seizure, the client frequently experiences drowsiness and postictal sleep. Answer A is incorrect because the client is able to move the extremities. Answer C is incorrect because the client can remember events before the seizure. Answer D is incorrect because the blood pressure is elevated.
The nurse is caring for a client who is unconscious following a fall. Which comment by the nurse will help the client become reoriented when he regains consciousness?
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Solution
Answer D is correct. Telling the client what happened and where he is helps with reorientation. Answer A does not explain what happened to the client; therefore, it is incorrect. Answer B is not helpful because the client regaining consciousness will not know where he is; therefore, the answer is incorrect. The nurse should not offer false reassurances, such as “everything will be alright”; therefore, answer C is incorrect.
A client with angina has an order for nitroglycerin ointment. Before applying the medication, the nurse should:
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Solution
Answer C is correct. The nurse should remove any remaining ointment before applying the medication again. Answer A is incorrect because it interferes with absorption. Answer B does not apply to the question of how to administer the medication; therefore, it is incorrect. Answer D is incorrect because the medication’s action is more immediate.
An adolescent with borderline personality disorders is hospitalized with suicidal ideation and self-mutilation. Which goal is both therapeutic and realistic for this client?
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Solution
Answer D is correct. Verbalizing feelings of anger and sadness to a staff member is an appropriate therapeutic goal for the client with a risk of self-directed violence. Answers A and C place the client in an isolated situation to deal with her feelings alone; therefore, they are incorrect. Answer B is incorrect because it does not allow the client to ventilate her feelings.
The nurse is assessing a multigravida, 36 weeks gestation for symptoms of pregnancy-induced hypertension and preeclampsia. The nurse should give priority to assessing the client for:
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Solution
Answer A is correct. The nurse should pay close attention to swelling in the client with preeclampsia. Facial swelling indicates that the client’s condition is worsening and blood pressure will be increased. Answer B is not related to the question; therefore, it is incorrect. Answer C is incorrect because ankle edema is expected in pregnancy. Diminished reflexes are associated with the use of magnesium sulfate, which is the treatment of preeclampsia; therefore, answer D is incorrect.
The nurse is providing dietary teaching for a client with Meniere’s disease. Which statement indicates that the client understands the role of diet in triggering her symptoms?
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Solution
Answer B is correct. The client with Meniere’s disease should limit the intake of foods that contain sodium. Answers A, C, and D have no relationship to the symptoms of Meniere’s disease; therefore, they are incorrect.
The nurse is developing a bowel-retraining plan for a client with multiple sclerosis. Which measure is likely to be least helpful to the client:
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Solution
Answer A is correct. It would not be helpful to limit the fluid intake of a client during bowel retraining. Answers B, C, and D would help the client; therefore, they are incorrect answers.
Which statement best describes the difference between the pain of angina and the pain of myocardial infarction?
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Solution
Answer A is correct. Pain associated with angina is relieved by rest. Answer B is incorrect because it is not a true statement. Answer C is incorrect because pain associated with angina can be referred to the jaw, the left arm, and the back. Answer D is incorrect because pain from a myocardial infarction can be referred to areas other than the left arm.
The recommended time for daily administration of Tagamet (cimetidine) is:
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Solution
Answer D is correct. Tagamet (cimetidine) should be administered in one dose at bedtime. Answers A, B, and C have incorrect times for dosing.