Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is teaching a client about managing diverticulosis. Which of the following statements should the nurse make?
A. "Limit fiber intake to 20 grams each day."
Increasing fiber intake is a key recommendation for managing diverticulosis.
B. "Decrease cellulose-containing foods in the diet."
Cellulose-containing foods, such as whole grains and vegetables, are important sources of dietary fiber and are encouraged for managing diverticulosis.
C. "Take stimulating laxatives as needed."
Stimulating laxatives are not recommended for managing diverticulosis and could potentially exacerbate symptoms.
D. "Limit daily fat intake to 30% or less."
Limiting fat intake to 30% or less is a dietary recommendation for managing diverticulosis. A high-fiber diet is also important to prevent diverticular inflammation.
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Full Explanation
Choice A rationale:
Increasing fiber intake is a key recommendation for managing diverticulosis.
Choice B rationale:
Cellulose-containing foods, such as whole grains and vegetables, are important sources of dietary fiber and are encouraged for managing diverticulosis.
Choice C rationale:
Stimulating laxatives are not recommended for managing diverticulosis and could potentially exacerbate symptoms.
Choice D rationale:
Limiting fat intake to 30% or less is a dietary recommendation for managing diverticulosis. A high-fiber diet is also important to prevent diverticular inflammation.
Similar Questions
A nurse is assessing a newborn who is 4 hr old. Which of the following findings should the nurse expect?
A. Bulging fontanels
Bulging fontanels are a sign of increased intracranial pressure, which is an abnormal finding in newborns. The nurse should assess for other signs of neurological impairment, such as lethargy, irritability, or seizures.
B. Blue hands and feet
Blue hands and feet, also known as acrocyanosis, are a normal finding in newborns who are 4 hr old. This is due to immature peripheral circulation and should resolve within 24 to 48 hr.
C. Generalized petechiae
Generalized petechiae are a sign of bleeding disorders, infection, or trauma, which are abnormal findings in newborns. The nurse should assess for other signs of bleeding, such as bruising, hematuria, or melena.
D. Flaring of the nares
Flaring of the nares is a sign of respiratory distress, which is an abnormal finding in newborns. The nurse should assess for other signs of respiratory distress, such as grunting, retractions, or cyanosis.
Full Explanation
Choice A rationale:
Bulging fontanels are a sign of increased intracranial pressure, which is an abnormal finding in newborns. The nurse should assess for other signs of neurological impairment, such as lethargy, irritability, or seizures.
Choice B rationale:
Blue hands and feet, also known as acrocyanosis, are a normal finding in newborns who are 4 hr old. This is due to immature peripheral circulation and should resolve within 24 to 48 hr.
Choice C rationale:
Generalized petechiae are a sign of bleeding disorders, infection, or trauma, which are abnormal findings in newborns. The nurse should assess for other signs of bleeding, such as bruising, hematuria, or melena.
Choice D rationale:
Flaring of the nares is a sign of respiratory distress, which is an abnormal finding in newborns. The nurse should assess for other signs of respiratory distress, such as grunting, retractions, or cyanosis.
A nurse is providing teaching to a client who has diverticulosis about identifying manifestations of diverticulitis. Which of the following client statements indicates an understanding of the teaching?
A. "I will have upper abdominal pain."
Upper abdominal pain is not a typical manifestation of diverticulitis. It is more commonly associated with conditions affecting the upper gastrointestinal tract.
B. "My abdomen will become distended."
Rationale: Diverticulitis is characterized by inflammation or infection of diverticula (small pouches) in the colon. Manifestations of diverticulitis can include abdominal pain (usually left lower quadrant), fever, nausea, vomiting, and changes in bowel habits. Abdominal distension may indicate worsening inflammation or complication of diverticulitis.
C. "My stools will be clay-colored."
Clay-colored stools are more characteristic of liver or bile duct disorders, not diverticulitis.
D. "I will experience gastric reflux."
Gastric reflux is not a common manifestation of diverticulitis. It is more related to gastroesophageal reflux disease (GERD) or other upper gastrointestinal issues.
Full Explanation
Choice A rationale:
Upper abdominal pain is not a typical manifestation of diverticulitis. It is more commonly associated with conditions affecting the upper gastrointestinal tract.
Choice B rationale:
Rationale: Diverticulitis is characterized by inflammation or infection of diverticula (small pouches) in the colon. Manifestations of diverticulitis can include abdominal pain (usually left lower quadrant), fever, nausea, vomiting, and changes in bowel habits.
Abdominal distension may indicate worsening inflammation or complication of diverticulitis.
Choice C rationale: Clay-colored stools are more characteristic of liver or bile duct disorders, not diverticulitis.
Choice D rationale: Gastric reflux is not a common manifestation of diverticulitis. It is more related to gastroesophageal reflux disease (GERD) or other upper gastrointestinal issues.
A nurse is developing a plan of care for a client who has epilepsy and was admitted after experiencing a tonic-clonic seizure. Which of the following interventions should the nurse include in the plan?
A. Ensure padded wrist restraints are in the client's room.
Padded wrist restraints are not appropriate unless there's a clear clinical indication to prevent self-harm or injury.
B. Initiate IV access for the client.
After a seizure, it's important to establish IV access for the client to administer medications, fluids, or other interventions if needed. Monitoring for possible postictal state, airway patency, and vital signs are also important components of care.
C. Administer lorazepam every 4 hr to sedate the client.
Administering lorazepam every 4 hours is not a standard protocol for post-seizure management and could lead to excessive sedation.
D. Place an incontinence brief on the client
Placing an incontinence brief is not necessary unless there's a specific indication, and it doesn't directly relate to post-seizure care.
Full Explanation
Choice A rationale:
Padded wrist restraints are not appropriate unless there's a clear clinical indication to prevent self-harm or injury.
Choice B rationale:
After a seizure, it's important to establish IV access for the client to administer medications, fluids, or other interventions if needed. Monitoring for possible postictal state, airway patency, and vital signs are also important components of care.
Choice C rationale:
Administering lorazepam every 4 hours is not a standard protocol for post-seizure management and could lead to excessive sedation.
Choice D rationale:
Placing an incontinence brief is not necessary unless there's a specific indication, and it doesn't directly relate to post-seizure care.