Which food item interferes with the effectiveness of warfarin?

Correct Answer: D

Rationale: Broccoli is high in vitamin K, which can affect the effectiveness of warfarin. Warfarin is an anticoagulant medication that functions by reducing the activity of vitamin K in the body. When one consumes broccoli, which is rich in vitamin K, it could counteract the anticoagulant effect of warfarin, thereby interfering with its effectiveness. On the other hand, cauliflower, zucchini, and green beans do not have significant levels of vitamin K and hence, are not known to impact the effectiveness of warfarin.

Correct Answer: D

Rationale: The 'Medicine and Treatment Record' is the document that maintains a comprehensive log of all medications and treatments provided on a routine basis. It does not refer to the 'Discharge Summary', which is a clinical report prepared by healthcare professionals at the end of a hospital stay or series of treatments. The 'Nursing Health History and Assessment Worksheet' is used to gather comprehensive data about the patient's health history and current health status, but it does not record ongoing treatment details. The 'Nursing Kardex' is a patient care information system used to quickly communicate patient needs, but it does not consistently record all medications and treatments provided.

Correct Answer: A

Rationale: The primary objective when dealing with cases of child abuse is to ensure the safety of the child and any siblings. This means creating a secure environment free from harm, which is why choice 'A' is the correct answer. While choices 'B', 'C', and 'D' might be subsequent steps in a comprehensive plan to deal with the situation, they are not the immediate priority. Understanding abusive behavioral patterns or improving the relationship with the counselor will not directly lead to the child's safety. Likewise, teaching the mother to apply verbal discipline doesn't guarantee the child's safety if the abusive behavior continues. Therefore, these options are not the most important initial goal.

Correct Answer: A

Rationale: The correct answer is A, which directs the client to avoid foods such as smoked meats and frozen dinners. These types of foods are typically high in sodium, making them unsuitable for a low-sodium diet. Option B is incorrect because foods with less than 4g of sodium might still be high in sodium for individuals on low-sodium diets. The daily recommended intake of sodium for a low-sodium diet is usually around 1.5g to 2g. Hence, 4g of sodium in a single food product can be excessive. Option C is incorrect as soy sauce, although a different source of flavor, is also high in sodium and should be used sparingly, if at all, in a low-sodium diet. Option D is incorrect because processed and prepared foods are usually not low in sodium. In fact, these foods often have high sodium content due to added salts and preservatives.

Correct Answer: C

Rationale: The correct answer is 'An individual who consumes a diet high in processed foods.' Processed foods are often deficient in water-soluble vitamins such as vitamin C and B vitamins, which can lead to deficiencies. On the other hand, fruits, vegetables, and organ meats are rich sources of these vitamins, so individuals who consume these regularly are less likely to develop deficiencies. While dairy products do contain some water-soluble vitamins, they are not depleted as quickly as they are in a diet high in processed foods, making a deficiency less likely.

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: In preparing a patient for a cleansing enema, the nurse typically positions the patient in the left lateral position. This position allows for the best flow of the solution due to the anatomical configuration of the colon. The right lateral position, right Sim's position, and left Sim's position are not typically used for this procedure. The rationale provided initially is incorrect as it pertains to lung expansion and postural drainage, which are not relevant to a cleansing enema procedure.

Correct Answer: D

Rationale: The correct answer is 'D: Risk for infection.' An indwelling urinary catheter poses a significant risk for infection due to its invasive nature and the increased susceptibility to urinary tract infections. While 'B: Impaired urinary elimination' and 'C: Impaired skin integrity' may also be concerns for a patient with an indwelling urinary catheter, the immediate risk of infection is the priority. 'A: Self-esteem disturbance' is not typically a priority nursing diagnosis for a patient with an indwelling urinary catheter because the focus is primarily on infection prevention and management to ensure patient safety and well-being.

Correct Answer: A

Rationale: A registered nurse is responsible for a group of patients from their admission to their discharge. This responsibility encompasses assessing patient needs, formulating care plans, administering medications, monitoring patient progress, and coordinating with other members of the healthcare team. Choice B is not entirely accurate because, even though nurses often work with nursing aides, the nurses themselves hold the ultimate responsibility for the overall care of the patient. Choices C and D are incorrect as they depict an incomplete and inaccurate representation of a nurse's role, which extends beyond administrative duties and equipment maintenance to primarily focus on direct patient care.