Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reinforcing teaching with the parents of a preschool-age child who has a new diagnosis of celiac disease.
Which of the following foods should the nurse recommend?
A. Wheat toast and jelly
Should be avoided as they contain wheat or barley.
B. Graham crackers with peanut buter
Should be avoided as they contain wheat or barley.
C. Beef barley soup
Should be avoided as they contain wheat or barley.
D. Corn tortillas with black beans
Is a suitable choice because corn is a gluten-free grain and black beans are also gluten-free. This option provides a balanced and nutritious meal for a child with celiac disease. It is important for individuals with celiac disease to carefully read food labels and choose gluten- free alternatives to ensure their diet is free of gluten-containing ingredients.
This question is an excerpt from Nurse Dive's nursing test bank - VATI PN Comprehensive Predictor 2020 Proctored Exam. Take the full exam now
Full Explanation
d. Corn tortillas with black beans.
Explanation:
Celiac disease is an autoimmune disorder that requires strict adherence to a gluten-free diet. Gluten is a protein found in wheat, barley, and rye. Therefore, options a, b, and c should be avoided as they contain wheat or barley.
Option d, corn tortillas with black beans, is a suitable choice because corn is a gluten-free grain and black beans are also gluten-free. This option provides a balanced and nutritious meal for a child with celiac disease. It is important for individuals with celiac disease to carefully read food labels and choose gluten- free alternatives to ensure their diet is free of gluten-containing ingredients.
Similar Questions
A nurse is contributing to the discharge plans for four clients. The nurse should identify that which of the following clients requires an interdisciplinary care conference?
A. A client who had surgery for cataract removal and lives in a rural location.
Clients who had surgery for cataract removal and live in a rural location (option a) may require support with transportation and follow-up appointments, but it does not necessarily warrant an interdisciplinary care conference.
B. A client who has hemiparesis and lives alone
An interdisciplinary care conference involves the collaboration of multiple healthcare professionals from different disciplines to develop a comprehensive care plan for a client. In this scenario, the client with hemiparesis who lives alone requires an interdisciplinary care conference because their condition and living situation present complex challenges.
C. A client who requires assistance to pay for dressing supplies
A client who requires assistance to pay for dressing supplies (option c) may benefit from financial counseling or resources, but it does not typically require the involvement of multiple healthcare professionals in a care conference.
D. A client who requires instruction regarding medication administration
A client who requires instruction regarding medication administration (option d) can typically receive education from a nurse or pharmacist without the need for an interdisciplinary care conference.
Full Explanation
b. A client who has hemiparesis and lives alone.
Explanation:
The correct answer is b. A client who has hemiparesis and lives alone.
An interdisciplinary care conference involves the collaboration of multiple healthcare professionals from different disciplines to develop a comprehensive care plan for a client. In this scenario, the client with hemiparesis who lives alone requires an interdisciplinary care conference because their condition and living situation present complex challenges.
Clients who had surgery for cataract removal and live in a rural location (option a) may require support with transportation and follow-up appointments, but it does not necessarily warrant an interdisciplinary care conference.
A client who requires assistance to pay for dressing supplies (option c) may benefit from financial counseling or resources, but it does not typically require the involvement of multiple healthcare professionals in a care conference.
A client who requires instruction regarding medication administration (option d) can typically receive education from a nurse or pharmacist without the need for an interdisciplinary care conference.
In contrast, the client with hemiparesis who lives alone may require input from various professionals such as physical therapists, occupational therapists, social workers, and home healthcare providers to address their physical limitations, safety concerns, and support needs. Therefore, an interdisciplinary care conference is necessary to develop a comprehensive discharge plan that addresses all aspects of their care and promotes their well-being in the community.
A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The nurse is preparing to change the client's surgical dressing. Which of the following actions should the nurse take to demonstrate sensitivity to age-related changes?
A. Ask the client to help with the dressing change
A. Asking the client to assist with a surgical dressing change following a total hip arthroplasty may be inappropriate due to the client's postoperative physical limitations and hip precautions. While fostering independence is generally positive, it does not specifically address the physiological age-related changes of the integumentary system. The primary concern in this scenario is protecting the integrity of the client's fragile skin during adhesive removal.
B. Wait for the client to approach the nurse for assistance
B. Waiting for a client to request assistance for a scheduled postoperative dressing change is a deviation from the standard plan of care and proactive nursing management. Postoperative wound care is a scheduled clinical priority to monitor for infection and promote healing. This action does not demonstrate sensitivity to age-related physiological changes and could potentially lead to delayed detection of surgical site complications or wound dehiscence.
C. Use paper tape for securing the new dressing
C. Using paper tape is the most appropriate action because older adults possess a thinner stratum corneum and diminished cohesion between the dermis and epidermis. Traditional plastic or silk adhesives can cause epidermal stripping and skin tears upon removal due to their high tackiness. Paper tape provides sufficient securement for the surgical dressing while minimizing the risk of mechanical injury to the sensitive, translucent skin of an elderly patient.
D. Apply the dressing loosely over the incision
D. Applying a dressing loosely over a fresh surgical incision is contraindicated as it fails to provide an adequate microbial barrier and does not support wound healing. A loose dressing may shift, causing friction against the incision line or allowing contaminants to reach the surgical site. To demonstrate age-related sensitivity, the nurse must ensure the dressing is secure while using materials that are gentle on the surrounding atrophic skin.
Full Explanation
Rationale:
A. Asking the client to assist with a surgical dressing change following a total hip arthroplasty may be inappropriate due to the client's postoperative physical limitations and hip precautions. While fostering independence is generally positive, it does not specifically address the physiological age-related changes of the integumentary system. The primary concern in this scenario is protecting the integrity of the client's fragile skin during adhesive removal.
B. Waiting for a client to request assistance for a scheduled postoperative dressing change is a deviation from the standard plan of care and proactive nursing management. Postoperative wound care is a scheduled clinical priority to monitor for infection and promote healing. This action does not demonstrate sensitivity to age-related physiological changes and could potentially lead to delayed detection of surgical site complications or wound dehiscence.
C. Using paper tape is the most appropriate action because older adults possess a thinner stratum corneum and diminished cohesion between the dermis and epidermis. Traditional plastic or silk adhesives can cause epidermal stripping and skin tears upon removal due to their high tackiness. Paper tape provides sufficient securement for the surgical dressing while minimizing the risk of mechanical injury to the sensitive, translucent skin of an elderly patient.
D. Applying a dressing loosely over a fresh surgical incision is contraindicated as it fails to provide an adequate microbial barrier and does not support wound healing. A loose dressing may shift, causing friction against the incision line or allowing contaminants to reach the surgical site. To demonstrate age-related sensitivity, the nurse must ensure the dressing is secure while using materials that are gentle on the surrounding atrophic skin.
A nurse is caring for a child who has terminal cancer.
Which of the following responses by the child's siblings should the nurse expect?
A. The adolescent brother criticizes the parents' plan to have a funeral service.
Adolescents may have complex feelings about death, including anger, denial, or confusion. However, it would be less common for a typical adolescent to criticize funeral arrangements. Most adolescents, while they might struggle with the idea of death, are more likely to be concerned about how it will affect their family dynamics or express sadness or anxiety. Criticizing the funeral plan would likely be an expression of unresolved grief or emotional turmoil but not necessarily the most typical response in this situation.
B. The school-age sister views death as being a type of temporary sleep.
This response aligns with developmental stages. School-age children (around ages 5-9) often have a more concrete understanding of death but may still see it as reversible or temporary, such as a long sleep. This is a normal way children in this age group might conceptualize death before they fully understand its permanence. It's common for them to express the idea that the person who has died will wake up or return in some way, as their cognitive understanding is still developing.
C. The adolescent brother fears the terminal illness is contagious.
While younger children (especially toddlers or early school-age children) may be more likely to fear that death or illness is contagious, adolescents generally have a better understanding of illness and its transmission. By the time children are in adolescence, they typically grasp that terminal illnesses like cancer are not contagious. Therefore, this response is less likely for an adolescent sibling.
D. The school-age sister is concerned about the impact of her sibling's death on herself.
While it is true that children of all ages can be concerned about the impact of death on their own lives, school-age children are more likely to express these concerns in more self-centered ways (e.g., fear of being abandoned or sadness about the change in family dynamics). This is a possible response, but it's a bit broader than the typical developmental response of a school-age child, which tends to involve viewing death as temporary or reversible
Full Explanation
B. The school-age sister views death as being a type of temporary sleep:
This response aligns with developmental stages. School-age children (around ages 5-9) often have a more concrete understanding of death but may still see it as reversible or temporary, such as a long sleep. This is a normal way children in this age group might conceptualize death before they fully understand its permanence. It's common for them to express the idea that the person who has died will wake up or return in some way, as their cognitive understanding is still developing.