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1. A client has bilateral eye patches in place following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating?
- A. Assign an assistive personnel to feed the client.
- B. Explain to the client that their tray is here and guide their hands to it.
- C. Describe to the client the location of the food on the tray.
- D. Ask the client if they would prefer a liquid diet.
Correct answer: C
Rationale: When a client has bilateral eye patches, promoting independence in eating is crucial to maintain dignity and autonomy. Describing the location of the food on the tray enables the client to locate and feed themselves. Assigning assistive personnel to feed the client (Choice A) takes away their independence. Merely informing the client that the tray is here and guiding their hands to it (Choice B) does not empower the client to eat independently. Asking if the client prefers a liquid diet (Choice D) is not directly addressing the client's ability to independently eat the current meal.
2. Which mental health disorder can lead to the erosion of lingual enamel, enlarged parotid glands, palatal bruising, and dentinal hypersensitivity?
- A. Bulimia
- B. Anorexia nervosa
- C. Depression
- D. Schizophrenia
Correct answer: A
Rationale: The correct answer is A: Bulimia. Bulimia involves repeated episodes of binge eating followed by purging, which can lead to the erosion of lingual enamel, enlarged parotid glands, palatal bruising, and dentinal hypersensitivity. This behavior exposes the teeth to stomach acid during purging, causing damage to the enamel. Choices B, C, and D are incorrect because these conditions are not typically associated with the specific oral health issues mentioned in the question.
3. Which statement by a client indicates a need for further teaching about food safety?
- A. I will use the food before the expiration date listed on the package.
- B. I will wash my strawberries before I eat them.
- C. I will drink unpasteurized milk as it has many gut-healthy probiotics.
- D. I will wash my hands after I prepare raw chicken.
Correct answer: C
Rationale: The correct answer is C because drinking unpasteurized milk can contain harmful bacteria, which poses a risk to food safety. Choice A is correct as it emphasizes using food before the expiration date. Choice B is also correct as washing fruits before consumption is a good food safety practice. Choice D is correct as well since washing hands after handling raw chicken is crucial to prevent cross-contamination. Therefore, choice C is the only statement that indicates a need for further teaching on food safety.
4. The nurse interprets the statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!†as important in documenting in which of the following areas of mental status examination?
- A. Thought content
- B. Mood
- C. Affect
- D. Attitude
Correct answer: C
Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.
5. Which food item interferes with the effectiveness of warfarin?
- A. Cauliflower
- B. Zucchini
- C. Green beans
- D. Broccoli
Correct answer: D
Rationale: Broccoli is high in vitamin K, which can affect the effectiveness of warfarin. Warfarin is an anticoagulant medication that functions by reducing the activity of vitamin K in the body. When one consumes broccoli, which is rich in vitamin K, it could counteract the anticoagulant effect of warfarin, thereby interfering with its effectiveness. On the other hand, cauliflower, zucchini, and green beans do not have significant levels of vitamin K and hence, are not known to impact the effectiveness of warfarin.
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