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1. A client with stomatitis is receiving teaching from a nurse. Which of the following client statements indicates a need for further teaching?
- A. "I will drink liquids through a straw."?
- B. "I will season foods with dried spices before cooking."?
- C. "I will rinse my mouth with baking soda and water frequently."?
- D. "I will eat frozen bananas as a snack."?
Correct answer: C
Rationale: The correct answer is, "I will rinse my mouth with baking soda and water frequently."? Stomatitis is an inflammation of the mucous lining in the mouth, and rinsing with baking soda and water can be too abrasive and further irritate the condition. Choices A, B, and D are appropriate self-care measures for a client with stomatitis and do not indicate a need for further teaching.
2. Why is there an ethical dilemma?
- A. Because the law does not clearly state what is right from what is wrong
- B. Because morality is subjective and it differs from each individual
- C. Because the patient's right coincide with the nurse's responsibility
- D. Because the nurse lacks ethical knowledge to determine what action is correct and what action is unethical
Correct answer: C
Rationale: The correct answer is C because an ethical dilemma arises when the patient's rights conflict with the nurse's responsibilities, requiring a careful balance to ensure ethical care delivery. Choices A and B are incorrect because ethical dilemmas are not solely about legal or subjective moral issues. Choice D is incorrect as nurses are generally equipped with ethical knowledge through education and training, and ethical dilemmas are more about conflicting values and responsibilities rather than a lack of knowledge.
3. What side effect is commonly associated with ECT?
- A. Transient loss of memory, confusion, and disorientation
- B. Nausea and vomiting
- C. Fractures
- D. Hypertension and increased heart rate
Correct answer: A
Rationale: The correct answer is A, as Electroconvulsive Therapy (ECT) is commonly associated with side effects such as transient loss of memory, confusion, and disorientation. While nausea and vomiting (Choice B) can occur, they are not as common as the memory-related side effects. Fractures (Choice C) are unlikely unless a mishap occurs during the procedure. Hypertension and increased heart rate (Choice D) might occur during the procedure due to the physiological stress of the treatment, but these are not the most commonly associated side effects. The rationale provided did not effectively explain this, so it's important to note that ECT is a procedure often used for severe depression and other mental illnesses, and understanding its side effects is crucial for patient safety and effective care.
4. What is the purpose of the cuff in a Tracheostomy tube?
- A. Separate the upper and lower airway
- B. Separate trachea from the esophagus
- C. Separate the larynx from the nasopharynx
- D. Secure the placement of the tube
Correct answer: B
Rationale: The purpose of the cuff in a Tracheostomy tube is to separate the trachea from the esophagus. The cuff helps prevent aspiration by creating a seal that separates the trachea from the esophagus, reducing the risk of food or fluids entering the lungs. Choices A, C, and D are incorrect because the cuff's primary function in a Tracheostomy tube is to prevent aspiration rather than separating the upper and lower airway, larynx from the nasopharynx, or securing the placement of the tube.
5. A nurse is providing teaching to the parent of an infant about introducing solid foods. The nurse should recommend that which of the following foods be introduced first?
- A. Strained fruits
- B. Pureed meats
- C. Cooked egg whites
- D. Iron-fortified cereal
Correct answer: D
Rationale: When introducing solid foods to infants, it is recommended to start with iron-fortified cereal as it is easily digestible and a good source of iron, an important nutrient for infants around 6 months of age. Strained fruits are usually introduced later due to their natural sugars. Pureed meats can be introduced after iron-fortified cereals to provide additional protein and iron. Cooked egg whites should be avoided until the infant is at least one year old to reduce the risk of allergies.
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