Which food is a reliable source of B12 for a pregnant vegan client?

Correct Answer: C

Rationale: Fortified soy milk is a reliable source of vitamin B12 for pregnant vegan clients as it is usually enriched with this vitamin. The other options, while nutritious, are not reliable sources of B12 for vegans. Soybeans may not provide enough B12, algae contains B12 analogs that the human body cannot utilize, and the B12 content in sea vegetables can fluctuate, potentially not providing the necessary daily intake.

Correct Answer: A

Rationale: Critical incident stress management is a process that provides individuals with education about recognizing stress reactions and strategizing management techniques for handling stress after a disaster. Choice B, 'Follow-up', is incorrect because it generally refers to continuing care after initial treatment, not specifically to stress management education. Choice C, 'Debriefing', is a process where individuals involved in a critical event are brought together to discuss the event and their reactions to it. It can be part of the critical incident stress management process, but it doesn't cover the whole process. Choice D, 'Defusion', is a technique used in the immediate aftermath of a traumatic event to help individuals process their experiences, but it does not encompass the full range of education about stress recognition and management strategies.

Correct Answer: A

Rationale: The correct location to auscultate the apex beat is at the fifth intercostal space, along the midclavicular line. This is where the apical impulse, also known as the point of maximal impulse (PMI), can be best heard. Choices B, C, and D are incorrect anatomical locations for auscultating the apex beat, which makes them incorrect choices. Auscultating at the correct location allows healthcare providers to assess the heart's function and detect any abnormalities in heart sounds, which is crucial for comprehensive patient care.

Correct Answer: B

Rationale: The correct answer is B: Hamburger, fries, and soft drink. This meal is considered the least nutritious among the options provided due to its high content of unhealthy fats, processed carbohydrates, and added sugars, which lack essential nutrients. On the other hand, choice A: Ham sandwich, apple, and milk, offers a balanced meal with protein, fiber, vitamins, and calcium. Choice C: Macaroni and cheese, green beans, and peaches, provides a mixture of carbohydrates, vegetables, and fruits. Choice D: Meatloaf, broccoli, and pear slices, includes protein, fiber, and vitamins. Thus, all choices except B provide a more balanced and nutritious meal.

Correct Answer: D

Rationale: When measuring blood pressure, the cuff should be inflated to 30 mmHg above the estimated systolic blood pressure based on palpation of the radial or brachial artery. This ensures an accurate blood pressure measurement. Choices A, B, and C are incorrect. Deflating the cuff fully before starting a second reading (Choice A) does not directly relate to the position of the cuff during a reading. Deflating the cuff quickly after inflating to 180 mmHg (Choice B) is not recommended because it can potentially lead to inaccurate readings. While ensuring the cuff is large enough to wrap around the upper arm positioned 1 cm above the brachial artery is important (Choice C), this alone does not guarantee an accurate blood pressure reading. The correct inflation based on palpation is the key element for accuracy, which is why Choice D is correct.

Correct Answer: D

Rationale: The correct answer is 'Termination'. This phase of the therapeutic relationship is when the nurse informs the patient about the conclusion of therapy. It is during this phase that the nurse and the patient review the goals and progress made and also discuss the upcoming termination. The other phases are not the appropriate times for discussing termination. 'Pre-orientation' is the phase before the nurse-patient relationship is established; 'Orientation' is when the nurse and patient get to know each other and set goals; and 'Working' is when these goals are pursued. Therefore, choices A, B, and C are incorrect.

Correct Answer: A

Rationale: In the context of blood administration, it's crucial for the nurse to stay with the client for the first 15 minutes. This is because most adverse reactions are likely to occur within this initial period. Monitoring the client closely during this time allows for immediate detection and response to any potential reactions. Choice B, staying with the client for the entire period of blood administration, is not typically feasible or necessary, although regular checks should be conducted. Running the infusion at a faster rate during the first 15 minutes (Choice C) is incorrect as this can actually increase the risk of adverse reactions. Informing the client to notify the staff immediately for any adverse reaction (Choice D) is an important practice, but it is not the most direct way for the nurse to monitor for adverse reactions.

Correct Answer: D

Rationale: The correct answer is D: Potential risk of foodborne illness. Patients undergoing chemotherapy have compromised immune systems, making them more susceptible to foodborne illnesses. Chemotherapy can reduce the count of white blood cells, which impairs the body's ability to fight off infections from bacteria or other pathogens that might be present in food. Therefore, the prevention of foodborne illnesses is a critical concern for these patients. Choices A, B, and C, while they represent valid concerns for food safety in general, are not the primary concern for patients undergoing chemotherapy. These patients are at a heightened risk of experiencing severe complications from foodborne illnesses, making it a more significant concern than potential food allergies, food-drug interactions, or pesticide residues.

Correct Answer: D

Rationale: The correct answer is 'Develop methods for data collection' (Choice D). In the nursing research process, after the research problem has been identified, the next step would typically be to develop methods for how data will be collected. This is essential to effectively address the research problem. 'Review related literature' (Choice A), while an important step, usually occurs after the research problem has been identified and before methods for data collection are developed. 'Seek permission from the hospital administrator' (Choice B) might be necessary at some point in certain situations, but it is not the immediate next step in the research process. 'Identify the research problem' (Choice C) would typically come before developing methods for data collection. Therefore, according to the typical sequence of steps in the nursing research process, Choice D is correct.