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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. What is the most common type of kidney stone?
- A. Cystine
- B. Calcium
- C. Struvite
- D. Uric acid
Correct answer: B
Rationale: The most common type of kidney stone is calcium-based, specifically calcium oxalate. This is usually due to high calcium levels in the urine, which can be caused by dietary factors or certain metabolic disorders. Cystine stones, on the other hand, are less common and occur in individuals with a hereditary disorder leading to excessive excretion of certain amino acids. Struvite stones are often formed in response to an infection. Uric acid stones may occur in individuals who do not consume sufficient fluids or who lose too much fluid, among other factors. Therefore, while all these substances can form stones in the kidneys, calcium stones are the most common.
3. In preparation for ECT, the nurse knows that it is almost similar to that of:
- A. ECG
- B. General Anesthesia
- C. EEG
- D. MRI
Correct answer: B
Rationale: The correct answer is B: General Anesthesia. In preparation for ECT (Electroconvulsive Therapy), the nurse should be aware that it is almost similar to the process of administering general anesthesia. This similarity is crucial as it involves sedation and muscle relaxation to ensure safety during the procedure. Choice A (ECG) is incorrect because ECT and ECG (Electrocardiogram) serve different purposes and involve distinct procedures. Choice C (EEG) is incorrect as EEG (Electroencephalogram) measures brain activity and is not directly related to ECT. Choice D (MRI) is also incorrect as MRI (Magnetic Resonance Imaging) is a diagnostic imaging procedure that does not involve sedation or muscle relaxation like ECT and general anesthesia.
4. A client was rushed in the E.R showing a whitish, leathery and painless burned area on his skin. The nurse is correct in classifying this burn as:
- A. First degree burn C. Third degree burn
- B. Second degree burn D. Partial thickness burn
- C.
- D.
Correct answer: B
Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.
5. A nurse is providing teaching to a group of parents of newborns who are planning to formula feed. Which of the following statements by a parent indicates a need for further teaching?
- A. "I will give formula to my baby at room temperature."
- B. "I will ensure my baby's feeds last 10 to 15 minutes."
- C. "I will burp my baby halfway through each feeding."
- D. "I will watch for signs my baby is full and stop the feeding."
Correct answer: B
Rationale: The correct answer is, "I will ensure my baby's feeds last 10 to 15 minutes." This statement indicates a need for further teaching because it suggests a strict time limit for feedings, which may not be appropriate for a newborn. Newborns should be allowed to feed as long as they want, typically around 20-30 minutes per breast if breastfeeding, or on-demand with formula. Choices A, C, and D demonstrate proper feeding practices such as feeding at room temperature, burping halfway through each feeding, and watching for signs of fullness to stop the feeding, which are all appropriate responses by a parent of a formula-fed newborn.
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