The nurse is teaching a client who has pernicious anemia about necessary dietary changes. Which statement by the client indicates understanding about those changes?

Correct Answer: A

Rationale: In this scenario, option A is the correct answer because pernicious anemia is characterized by the body's inability to properly absorb vitamin B12. Animal proteins such as fish and meat are rich sources of vitamin B12, which is essential for addressing the deficiency in individuals with pernicious anemia. By increasing the intake of these foods, the client can help replenish their vitamin B12 levels and support red blood cell production. Option B, focusing on increasing fats and carbohydrates, is incorrect because these nutrients do not directly address the vitamin B12 deficiency associated with pernicious anemia. While a balanced diet includes fats and carbohydrates, they are not the primary concern when managing this specific condition. Option C, suggesting the avoidance of dairy products completely, is also incorrect. Dairy products are not directly related to the treatment of pernicious anemia unless the individual has a specific intolerance or allergy to dairy. Dairy products do not play a significant role in addressing the vitamin B12 deficiency seen in pernicious anemia. Option D, emphasizing the consumption of more fruits and vegetables, is incorrect in the context of pernicious anemia. While fruits and vegetables are important components of a healthy diet, they do not provide significant amounts of vitamin B12, which is crucial for managing pernicious anemia. In an educational context, it is essential for nurses and healthcare providers to understand the specific dietary requirements for different health conditions. By teaching clients about the importance of consuming foods rich in vitamin B12, like animal proteins, nurses can empower individuals with pernicious anemia to make informed dietary choices that support their health and well-being. This knowledge equips clients to actively participate in managing their condition and improving their overall quality of life.

Correct Answer: A

Rationale: The correct answer is A) Hold the magnesium sulfate. Deep tendon reflexes of 0 to 1+ indicate possible magnesium toxicity. Magnesium sulfate is a medication commonly used to prevent seizures in patients with preeclampsia. High levels of magnesium can lead to respiratory depression, cardiac arrest, and neuromuscular blockade. Therefore, it is critical for the nurse to recognize the signs of magnesium toxicity, such as diminished reflexes, and take immediate action by withholding the medication to prevent further complications. Option B) Ask the provider to order a 24-hour UA is incorrect because urinary analysis does not directly address the issue of magnesium toxicity indicated by the abnormal reflexes. Option C) Assess the woman's temperature is incorrect as temperature assessment does not provide information specifically related to magnesium toxicity. Option D) Take the woman's blood pressure is incorrect as blood pressure monitoring is important in the care of a patient receiving magnesium sulfate but is not the priority when abnormal reflexes suggest potential toxicity. Educational Context: Understanding the importance of monitoring for signs of magnesium toxicity is crucial for nurses caring for patients receiving this medication. Recognizing and responding promptly to these signs can prevent serious complications and ensure patient safety. Nurses must be knowledgeable about the side effects and potential toxicities of medications they administer to provide safe and effective care to their patients.

Correct Answer: B

Rationale: In the context of a client with acute respiratory distress syndrome (ARDS), the correct answer is option B) Urine output decreases from 30 mL/hr to 25 mL/hr. Decreased cardiac output in ARDS can lead to reduced kidney perfusion, resulting in a decrease in urine output below the normal range of 30 mL/hr. This finding indicates inadequate cardiac function to adequately perfuse the kidneys, supporting the nursing diagnosis of Decreased Cardiac Output. Option A) Blood pressure improves from 90/50 to 100/60 mmHg suggests an improvement in perfusion pressure, which would not support a diagnosis of Decreased Cardiac Output. Option C) Oxygen saturation increases from 88% to 92% indicates improved oxygenation, not cardiac output. Option D) Pulse decreases from 120 beats/min to 110 beats/min could suggest a decreased workload on the heart, but it does not directly reflect decreased cardiac output. Educationally, understanding the relationship between cardiac output and kidney perfusion is crucial for nurses caring for patients with ARDS. Monitoring urine output can provide valuable information about cardiac function and tissue perfusion. Recognizing the significance of urinary changes in the context of cardiac output can guide nursing interventions and improve patient outcomes in critical care settings.

Correct Answer: A

Rationale: In the context of caring for a client with COPD, selecting small, frequent meals (Option A) is the most appropriate intervention to meet nutritional needs. This choice is correct because it helps reduce the energy demand associated with eating, which in turn aids in minimizing the strain on the respiratory system and breathing effort. By opting for small, frequent meals, the client can maintain adequate nutrition without overwhelming their respiratory function. Options B, C, and D are incorrect choices for meeting the nutritional needs of a client with COPD. Restricting protein intake (Option B) is not recommended as protein is essential for maintaining muscle strength, which is crucial for respiratory function in COPD. Encouraging fasting (Option C) can lead to nutritional deficiencies and energy depletion, both of which can worsen the condition. Limiting fluid intake (Option D) can cause dehydration and thickening of respiratory secretions, making breathing more difficult for COPD patients. Educationally, understanding the rationale behind selecting small, frequent meals for clients with COPD is vital for nurses and healthcare providers. It highlights the importance of tailoring nutritional interventions to support respiratory function and overall well-being in individuals with chronic respiratory conditions. This knowledge equips healthcare professionals to provide holistic care that addresses not only medical needs but also nutritional considerations to optimize patient outcomes.

Correct Answer: C

Rationale: In assessing an adult client with respiratory syncytial virus (RSV), the nurse would expect to find myalgia (muscle pain) as a symptom, which is the correct answer (C). Myalgia is more commonly reported in adults with RSV due to the systemic effects of the viral infection on the body. In contrast, infants with RSV typically present with respiratory symptoms such as wheezing, which is why option D is incorrect. Option A, rhinorrhea (runny nose), is a common symptom in both adults and infants with RSV. Option B, fever, can also be present in both age groups. However, myalgia is a distinguishing symptom seen more often in adults with RSV. Understanding these differences in symptom presentation is crucial for nurses caring for patients with RSV. Recognizing the unique manifestations of the virus in different age groups can aid in accurate assessment, timely intervention, and appropriate management of the condition. By knowing these distinctions, nurses can provide targeted care and support to patients based on their specific symptoms and needs.