The nurse is providing education to a client about nutrition. Which foods should the client be instructed to limit in their diet? (Select all that apply)

Cured fat food

Vegetables

Canned soups

Processed snacks

Sugary drinks

Answer and Explanation

Correct Answer : A,C,D,E

Choice A Reason:

Cured fat foods, such as bacon, sausages, and other processed meats, are high in saturated fats and sodium. Consuming these foods in excess can lead to increased cholesterol levels and a higher risk of heart disease. Limiting these foods is essential for maintaining a healthy diet and reducing the risk of chronic diseases.

Choice B Reason:

Vegetables are generally low in calories and high in essential nutrients, including vitamins, minerals, and fiber. They are an important part of a balanced diet and should not be limited. Instead, increasing vegetable intake is often recommended for better health outcomes.

Choice C Reason:

Canned soups often contain high levels of sodium, which can contribute to high blood pressure and other cardiovascular issues. Limiting the intake of canned soups can help manage sodium consumption and promote better heart health.

Choice D Reason:

Processed snacks, such as chips, crackers, and packaged baked goods, are typically high in unhealthy fats, sugars, and sodium. These foods can contribute to weight gain, high blood pressure, and other health problems. Reducing the intake of processed snacks is beneficial for overall health.

Choice E Reason:

Sugary drinks, including sodas, fruit juices with added sugars, and energy drinks, are high in calories and can lead to weight gain and increased risk of type 2 diabetes. Limiting sugary drinks is crucial for maintaining a healthy weight and preventing chronic diseases.

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Correct Answer is C

Explanation

Choice A reason: Cover

Covering a wound with slough is not an appropriate intervention. Slough is a type of necrotic tissue that can impede the healing process by providing a medium for bacterial growth and preventing the formation of healthy granulation tissue. Simply covering the wound without addressing the slough can lead to infection and delayed healing.

Choice B reason: Clean

Cleaning the wound is a necessary step in wound care, but it is not sufficient on its own to address the presence of slough. While cleaning can help reduce the bacterial load and remove some debris, it does not effectively remove the slough itself. Slough often requires more targeted interventions such as debridement to be effectively managed.

Choice C reason: Debride

Debridement is the most appropriate intervention for a wound with slough. Debridement involves the removal of necrotic tissue, including slough, to promote a clean wound bed and facilitate the healing process. There are several methods of debridement, including autolytic, enzymatic, mechanical, and surgical, each with its own indications and benefits. Removing the slough allows for better assessment of the wound and promotes the formation of healthy granulation tissue.

Choice D reason: Leave Alone

Leaving a wound with slough alone is not advisable. Slough can harbor bacteria and impede the healing process, leading to chronic wounds and potential infection. Without intervention, the wound is unlikely to progress through the normal stages of healing.

A. Open the client’s visual acuity using a Snellen chart. B. Whisper none of the client’s ears while blocking the other. C. Ask the client to inspect up. D. Ask the client to smile.

Correct Answer is C

Explanation

Choice A Reason:

Open the client’s visual acuity using a Snellen chart is incorrect. This action assesses cranial nerve II (optic nerve), which is responsible for vision. The Snellen chart is used to measure visual acuity, not the function of cranial nerve VI

Choice B Reason:

Whisper none of the client’s ears while blocking the other is incorrect. This action assesses cranial nerve VIII (vestibulocochlear nerve), which is responsible for hearing and balance. Whispering tests the auditory function of this nerve.

Choice C Reason:

Ask the client to inspect up is correct. Cranial nerve VI (abducens nerve) controls the lateral rectus muscle, which is responsible for moving the eye outward. Asking the client to look up and outward helps assess the function of this nerve.

Choice D Reason:

Ask the client to smile is incorrect. This action assesses cranial nerve VII (facial nerve), which controls the muscles of facial expression. Smiling tests the motor function of this nerve.

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The nurse is providing education to a client about nutrition. Which foods should the client be instructed to limit in their diet? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client’s wound and notes there is slough present. What would be an appropriate intervention for this wound?

Correct Answer is C

Explanation

A nurse is preparing to assess a client. Which action should the nurse take to check cranial nerve VI?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. How should the nurse explain to the client how this method of oxygen delivery performs?

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A nurse is confirming with the client the informed consent signed earlier that day. The client then states, “I have changed my mind and do not want to have the procedure done.” What action should the nurse take?

A nurse is assessing a client with congestive heart failure (CHF). Which assessment tool will provide a reliable measure of fluid retention for this client?

A nurse is auscultating a client’s lung sounds and identifies crackles in the left lower lobe. Which intervention should the nurse take first?

A nurse is preparing to administer oral medications to a client. According to the Joint Commission, which are acceptable client identifiers? (Select all that apply.)

A nurse accidentally sticks her hand with a needle after administering an intramuscular (IM) injection to a client. Which action should the nurse take first?

A nurse is caring for a client diagnosed with end-stage liver cancer. Which response is an indication the client is in the denial phase of the grief process?