A nurse is providing dietary instructions to a client who has cardiovascular disease. The nurse should identify that which of following statements by the client indicates an understanding of the teaching?

"I will increase my intake of canned vegetables."

"I will drink whole milk with my cereal."

"I will limit my portions of meat to 8 ounces."

"I will use canola oil when making salad dressing”

Answer and Explanation

The Correct Answer is D

A) "I will increase my intake of canned vegetables.": This statement indicates a lack of understanding. Canned vegetables can be high in sodium, which is not advisable for individuals with cardiovascular disease. Fresh or frozen vegetables are usually better options.

B) "I will drink whole milk with my cereal.": Whole milk is higher in saturated fat and cholesterol, which can contribute to cardiovascular issues. Low-fat or non-fat milk would be a more appropriate choice for someone with cardiovascular disease.
C) "I will limit my portions of meat to 8 ounces.": While portion control is important, this statement does not reflect an understanding of the type of meat to consume. It’s not just about the portion size but also about choosing lean meats and limiting red and processed meats.

D) "I will use canola oil when making salad dressing.": This statement shows an understanding of dietary recommendations for cardiovascular health. Canola oil is a healthier choice due to its lower saturated fat content and higher levels of heart-healthy monounsaturated fats, making it a better option for someone managing cardiovascular disease.

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Correct Answer is C

Explanation

A) NG tube: A nasogastric (NG) tube is not typically required for a client with a seizure
disorder unless there are specific feeding or medication administration needs post-seizure. It is not standard equipment for seizure management.

B) Wrist restraints: While restraints may be used in some situations to prevent injury, they are not routinely placed in a seizure patient's room and could increase the risk of harm during a seizure. It is generally best to ensure a safe environment without restraints.

C) Oral airway: Having an oral airway available in the client's room is essential for managing airway patency during or after a seizure. It can help to maintain an open airway, especially if the client becomes unresponsive or is at risk of aspiration.

D) Tongue blade: Using a tongue blade to hold the mouth open during a seizure is not recommended, as it can cause injury to the client or the nurse. It's a common myth that it should be used to prevent biting the tongue, but doing so can lead to more harm than good.

A. Cheyne-Stokes respirations B. Altered level of consciousness C. Decorticate posturing D. Pupillary dilation

Correct Answer is B

Explanation

A) Cheyne-Stokes respirations: This pattern of breathing can indicate severe neurological impairment but typically arises after other signs of increased intracranial pressure (ICP) have emerged. It is more associated with significant brain dysfunction.

B) Altered level of consciousness: This is often the first sign of deteriorating neurological status in clients with increased ICP. Changes in consciousness can range from confusion and disorientation to lethargy or coma. Monitoring for these subtle shifts is crucial for early intervention.

C) Decorticate posturing: This is a sign of severe brain injury and indicates a significant level of impairment. However, it usually appears after alterations in consciousness and is not the initial sign.

D) Pupillary dilation: While changes in pupil size and reactivity are important indicators of neurological status, they often occur after a decline in consciousness. Altered consciousness typically precedes these changes.

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A nurse is providing dietary instructions to a client who has cardiovascular disease. The nurse should identify that which of following statements by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a seizure disorder. Which of the following equipment should the nurse place in the client's room?

Correct Answer is C

Explanation

A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status?

Correct Answer is B

Explanation

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A nurse is providing dietary instructions to a client who has cardiovascular disease. The nurse should identify that which of following statements by the client indicates an understanding of the teaching?

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