Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
When addressing the needs of a client with a newly diagnosed spinal cord injury, the nurse understands that which of the following are true about nutritional needs?
A. The client will be NPO until fitted for a halo vest
Rationale: Keeping the client NPO until fitted for a halo vest is not a standard practice, and nutritional support should be initiated as soon as possible.
B. A high calorie, high protein diet will be started within 3 days
Rationale: A high-calorie, high-protein diet is typically started within 3 days of a spinal cord injury to support healing and prevent muscle wasting.
C. High fiber and decreased protein is needed immediately after injury
Rationale: High fiber and decreased protein are not the immediate dietary needs after a spinal cord injury. High protein intake is important for tissue repair.
D. Low fiber and no protein is needed 2 days after the injury
Rationale: Low fiber and no protein would not be recommended 2 days after a spinal cord injury, as protein intake is crucial for healing and recovery.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Paediatrics Proctored Exam 1. Take the full exam now
Full Explanation
Choice A Rationale: Keeping the client NPO until fitted for a halo vest is not a standard practice, and nutritional support should be initiated as soon as possible.
Choice B Rationale: A high-calorie, high-protein diet is typically started within 3 days of a spinal cord injury to support healing and prevent muscle wasting.
Choice C Rationale: High fiber and decreased protein are not the immediate dietary needs after a spinal cord injury. High protein intake is important for tissue repair.
Choice D Rationale: Low fiber and no protein would not be recommended 2 days after a spinal cord injury, as protein intake is crucial for healing and recovery.
Similar Questions
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
A. "You should keep the diaphragm in place for at least 4 hours after intercourse."
Rationale: Keeping the diaphragm in place for at least 4 hours after intercourse is a recommendation, but it does not address the specific concern of the client wanting to continue using her diaphragm postpartum.
B. "You should have your provider refit you for a new diaphragm."
Rationale: Having the client's provider refit her for a new diaphragm is the appropriate instruction after childbirth. The size and shape of the cervix can change postpartum, affecting the fit of the diaphragm.
C. "You should use an oil-based vaginal lubricant when inserting your diaphragm."
Rationale: Using an oil-based vaginal lubricant can damage the diaphragm and is not recommended.
D. "You should store your diaphragm in sterile water after each use."
Rationale: Storing the diaphragm in sterile water after each use is not a standard practice. Proper cleaning and storage in a dry, cool place are recommended.
Full Explanation
Choice A Rationale: Keeping the diaphragm in place for at least 4 hours after intercourse is a recommendation, but it does not address the specific concern of the client wanting to continue using her diaphragm postpartum.
Choice B Rationale: Having the client's provider refit her for a new diaphragm is the appropriate instruction after childbirth. The size and shape of the cervix can change postpartum, affecting the fit of the diaphragm.
Choice C Rationale: Using an oil-based vaginal lubricant can damage the diaphragm and is not recommended.
Choice D Rationale: Storing the diaphragm in sterile water after each use is not a standard practice. Proper cleaning and storage in a dry, cool place are recommended.
A client with a new diagnosis of trigeminal neuralgia is receiving education to prevent triggering an acute onset. Which of the following will the nurse include in teaching?
A. Eat only cold foods
Rationale: Eating only cold foods is not a common recommendation for preventing trigeminal neuralgia flare-ups.
B. Massage the affected side multiple times a day
Rationale: Massaging the affected side multiple times a day is not typically recommended and may exacerbate symptoms.
C. Apply heat or cold to alleviate symptoms
Rationale: Applying heat or cold to alleviate symptoms can vary depending on individual preferences and is not a primary preventive measure for triggering an acute onset.
D. Use a soft bristle toothbrush and warmed mouthwash
Rationale: Using a soft bristle toothbrush and warmed mouthwash is a recommended preventive measure to avoid triggering acute episodes of trigeminal neuralgia. It helps reduce irritation to the affected nerves.
Full Explanation
Choice A Rationale: Eating only cold foods is not a common recommendation for preventing trigeminal neuralgia flare-ups.
Choice B Rationale: Massaging the affected side multiple times a day is not typically recommended and may exacerbate symptoms.
Choice C Rationale: Applying heat or cold to alleviate symptoms can vary depending on individual preferences and is not a primary preventive measure for triggering an acute onset.
Choice D Rationale: Using a soft bristle toothbrush and warmed mouthwash is a recommended preventive measure to avoid triggering acute episodes of trigeminal neuralgia. It helps reduce irritation to the affected nerves.
The primary caregiver of a client with newly diagnosed Alzheimer's disease states "I don't know how I will handle caring for my spouse with this disease". What is the nurse's best first response?
A. "You sound overwhelmed, can you tell me more?"
Rationale: "You sound overwhelmed, can you tell me more?" is an empathetic response that encourages the caregiver to express their feelings and concerns. It opens the door for effective communication and understanding.
B. "It will take time, but lot's of people do it"
Rationale: "It will take time, but lots of people do it" may be true, but it does not directly address the caregiver's emotional state or offer support.
C. "What do you think will be the hardest thing to handle?"
Rationale: "What do you think will be the hardest thing to handle?" is a probing question that can help identify specific concerns, but it may not be the most appropriate initial response.
D. "The entire health care team will manage most of the disease process
Rationale: "The entire healthcare team will manage most of the disease process" does not acknowledge the caregiver's emotions and concerns and may not provide the needed support.
Full Explanation
Choice A Rationale: "You sound overwhelmed, can you tell me more?" is an empathetic response that encourages the caregiver to express their feelings and concerns. It opens the door for effective communication and understanding.
Choice B Rationale: "It will take time, but lots of people do it" may be true, but it does not directly address the caregiver's emotional state or offer support.
Choice C Rationale: "What do you think will be the hardest thing to handle?" is a probing question that can help identify specific concerns, but it may not be the most appropriate initial response.
Choice D Rationale: "The entire healthcare team will manage most of the disease process" does not acknowledge the caregiver's emotions and concerns and may not provide the needed support.