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1. A nurse is providing teaching to a client with gastroesophageal reflux. Which of the following statements by the client indicates a need for further teaching?
- A. I should elevate the head of my bed while sleeping.
- B. I drink no more than 4 cups of coffee a day.
- C. I take my time when I am eating.
- D. I avoid foods and drinks made with chocolate.
Correct answer: B
Rationale: The correct answer is B: 'I drink no more than 4 cups of coffee a day.' Excessive coffee consumption can aggravate gastroesophageal reflux due to its acidic nature. Choices A, C, and D are all appropriate self-care measures for managing gastroesophageal reflux. Elevating the head of the bed while sleeping helps prevent acid reflux, eating slowly can reduce reflux episodes, and avoiding trigger foods like chocolate can help alleviate symptoms.
2. An adolescent client has bloodshot eyes, a voracious appetite, and dry mouth. Which drug abuse would the nurse most likely suspect?
- A. Marijuana
- B. Amphetamines
- C. Barbiturates
- D. Anxiolytics
Correct answer: A
Rationale: The symptoms described, including bloodshot eyes, a voracious appetite, and dry mouth, are consistent with marijuana use. Bloodshot eyes are a common side effect of marijuana due to its effect on blood vessels in the eyes. Marijuana also often causes an increase in appetite (known as 'the munchies') and can result in dry mouth. Amphetamines typically cause symptoms like increased alertness, energy, and decreased appetite. Barbiturates and anxiolytics would not typically cause bloodshot eyes, a voracious appetite, and dry mouth as described in the scenario. Therefore, the most likely drug abuse the nurse would suspect in this case is marijuana.
3. Without enough calcium, both males and females are at risk of osteoporosis.
- A. TRUE
- B. FALSE
- C.
- D.
Correct answer: A
Rationale: The statement is true. Both males and females are at risk of developing osteoporosis if they do not consume enough calcium. Calcium is essential for maintaining strong bones, and inadequate intake can lead to bone density loss and increase the risk of osteoporosis. Therefore, it is crucial for individuals of all genders to ensure they have an adequate calcium intake to support bone health. Choice B is incorrect because osteoporosis is a condition that can affect both males and females.
4. The nurse notes that the fall might also cause a possible head injury. The patient will be observed for signs of increased intracranial pressure which include:
- A. Narrowing of the pulse pressure
- B. Vomiting
- C. Periorbital edema
- D. A positive Kernig's sign
Correct answer: C
Rationale: Periorbital edema is a sign of increased intracranial pressure. It is caused by fluid accumulation around the eyes due to compromised drainage. Narrowing of the pulse pressure is more indicative of shock than increased intracranial pressure. While vomiting can be a sign of increased intracranial pressure, it is not as specific as periorbital edema. A positive Kernig's sign is associated with meningitis, not increased intracranial pressure.
5. A nurse is completing an admission assessment on an adolescent client who is vegan. Which breakfast item should the nurse recommend as a protein combination with their diet restriction?
- A. Bagel with cream cheese
- B. Wheat toast with jelly
- C. Oatmeal pancakes with peanut butter
- D. Eggs with tofu bacon
Correct answer: C
Rationale: The correct answer is C: Oatmeal pancakes with peanut butter. For a vegan client, it is important to recommend plant-based protein sources. Oatmeal pancakes with peanut butter offer a good protein combination that aligns with their dietary restriction. Choices A, B, and D are not suitable as they all contain animal-derived products, which are not suitable for a vegan diet.
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