Nursing Elites

1. When assessing a client with chronic pain, which of the following is the most reliable indicator of the client's pain?

• A. The client's vital signs.
• B. The client's self-report of pain.
• C. The client's body language.
• D. The client's medical history.

Correct answer: B

Rationale: The client's self-report of pain is the most reliable indicator of pain. Pain is a subjective experience, and the client's self-report provides direct insight into their perception of pain intensity, quality, and impact on daily life. Vital signs, body language, and medical history can offer additional information but may not accurately reflect the client's actual pain experience. Therefore, relying on the client's self-report ensures a more accurate assessment of their pain and helps in tailoring appropriate interventions and treatment plans.

2. When teaching a client how to perform self-catheterization, which of the following instructions should be included?

• A. Use sterile gloves during the procedure.
• B. Clean the catheter with alcohol after each use.
• C. Insert the catheter 2-4 inches into the urethra.
• D. Perform the procedure every 8 hours.

Correct answer: C

Rationale: To ensure effective drainage, the catheter should be inserted 2-4 inches into the urethra. This length allows the catheter to reach the bladder, bypass the urethral sphincters, and ensure proper drainage without causing discomfort or injury. Using sterile gloves, cleaning the catheter with alcohol, and performing the procedure every 8 hours are not accurate instructions for self-catheterization.

3. A client has a new diagnosis of hyperkalemia and is receiving teaching from a healthcare provider on dietary management. Which of the following statements should the healthcare provider include in the teaching?

• A. You should increase your intake of potassium-rich foods.
• B. You should decrease your intake of potassium-rich foods.
• C. You should avoid foods that contain lactose.
• D. You should increase your intake of dairy products.

Correct answer: B

Rationale: The correct answer is B: 'You should decrease your intake of potassium-rich foods.' Hyperkalemia is a condition characterized by excess potassium in the blood. To manage hyperkalemia effectively, it is crucial to reduce the intake of potassium-rich foods. This helps in lowering the overall potassium levels in the body and prevents complications associated with hyperkalemia. Choices A, C, and D are incorrect. Increasing the intake of potassium-rich foods (Choice A) would exacerbate hyperkalemia. Avoiding foods that contain lactose (Choice C) is not directly related to managing hyperkalemia. Increasing the intake of dairy products (Choice D) is not recommended as they can be a significant source of dietary potassium.

4. A client with celiac disease is being taught about dietary management. Which statement by the client indicates an understanding of the teaching?

• A. I should avoid foods that contain gluten.
• B. I should increase my intake of foods high in gluten.
• C. I should avoid foods that contain lactose.
• D. I should increase my intake of foods high in lactose.

Correct answer: A

Rationale: The correct answer is A: 'I should avoid foods that contain gluten.' Celiac disease requires the avoidance of gluten-containing foods to manage symptoms and prevent complications. Gluten is found in wheat, barley, and rye. Choices B, C, and D are incorrect as they do not align with the dietary requirements for managing celiac disease. Increasing intake of foods high in gluten or lactose would be detrimental for someone with celiac disease.

5. A client with a new diagnosis of type 2 diabetes mellitus is being taught about dietary management. Which of the following statements should the nurse include in the teaching?

• A. You should avoid foods that contain carbohydrates.
• B. You should decrease your intake of high-fiber foods.
• C. You should increase your intake of high-protein foods.
• D. You should monitor your carbohydrate intake.

Correct answer: D

Rationale: The correct answer is D: 'You should monitor your carbohydrate intake.' Monitoring carbohydrate intake is essential for managing blood glucose levels in clients with type 2 diabetes mellitus. By monitoring carbohydrate intake, individuals can make informed decisions about their dietary choices and better control their blood sugar levels. Avoiding foods that contain carbohydrates (choice A) is not advisable as carbohydrates are an essential nutrient that can be consumed in moderation. Decreasing intake of high-fiber foods (choice B) is not recommended as fiber is beneficial for glycemic control and overall health. Increasing intake of high-protein foods (choice C) is not the primary focus of dietary management for type 2 diabetes; while protein is important, it is more crucial to monitor carbohydrate intake for effective blood sugar management.

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