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Nurse reviewing nutrition guidelines with parents of 11 yo. Which parent statement should indicate to nurse that they understand guidelines for school-age children?
- A. She wants to eat as much as us, but we're afraid she'll be overweight.
- B. She skips lunch sometimes but we figure it's okay as long as she has healthy breakfast & dinner.
- C. We limit fast food restaurant meals to 3x/week now
- D. We reward her school achievements with point system instead of pizza or ice cream
Correct Answer: D
Rationale: The correct answer is D because it demonstrates understanding of the guidelines by promoting non-food rewards for school achievements, which helps instill healthy habits and a positive relationship with food. This approach encourages the child to associate success with non-food rewards, fostering a healthy attitude towards food and eating habits. Choices A, B, and C focus on the child's weight, meal skipping, and fast food consumption, which are not aligned with the guidelines for school-age children. These choices may promote unhealthy eating behaviors or weight concerns.
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A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take?
- A. Moves patient's arm in a full circle
- B. Moves patient's arm across the body as far as possible
- C. Moves patient's arm behind body, keeping elbow straight
- D. Moves patient's arm until thumb is upward and lateral to head with elbow flexed
Correct Answer: D
Rationale: The correct answer is D. To perform external rotation of the shoulder, the nurse should move the patient's arm until the thumb is upward and lateral to the head with the elbow flexed. This position optimally engages the external rotators of the shoulder joint, allowing for the desired movement. Choice A involves a full circle motion, which does not specifically target external rotation. Choice B focuses on adduction rather than external rotation. Choice C involves extension of the shoulder rather than external rotation. Therefore, the correct answer is D as it aligns with the anatomical movements required for external rotation of the shoulder joint.
A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. Which finding will indicate goal achievement for the nurse's action?
- A. Prevention of atelectasis
- B. Prevention of renal calculi
- C. Prevention of pressure ulcers
- D. Prevention of joint contractures
Correct Answer: D
Rationale: The correct answer is D, prevention of joint contractures. Passive ROM and splinting help maintain joint flexibility and prevent contractures in immobile patients. Contractures are abnormal shortening of muscles causing joints to remain in fixed positions. Preventing joint contractures is essential for preserving mobility.
A: Prevention of atelectasis is unrelated to passive ROM and splinting.
B: Prevention of renal calculi is not a direct outcome of passive ROM and splinting.
C: Prevention of pressure ulcers is important but not directly related to joint mobility.
In summary, the goal of the nurse's action is to prevent joint contractures, as immobility can lead to loss of joint motion.
Home health nurse is discussing dangers of food poisoning with client. What information should the nurse include? (Select all that apply)
- A. Most food poisoning is caused by viruses
- B. Immunocompromised individuals are at risk for complications from food poisoning
- C. Clients who are at risk should eat/drink only pasteurized dairy products
- D. Healthy people usually recover from illness in a few weeks
- E. Handling raw & fresh food separately to avoid cross-contamination may prevent food poisoning
Correct Answer: B,C,E
Rationale: The correct answers are B, C, and E.
B: Immunocompromised individuals are at higher risk for complications from food poisoning due to weakened immune systems.
C: Clients at risk should consume only pasteurized dairy products to reduce the risk of foodborne illnesses.
E: Handling raw and fresh food separately prevents cross-contamination, a common cause of food poisoning.
Incorrect options:
A: Most food poisoning is caused by bacteria, not viruses.
D: Healthy individuals typically recover from food poisoning in a few days, not weeks.
In summary, the correct answers focus on specific preventive measures and risks for vulnerable populations, while the incorrect options provide inaccurate information regarding the causes and outcomes of food poisoning.
A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in this patient?
- A. Increased appetite
- B. Increased diarrhea
- C. Increased metabolic rate
- D. Altered nutrient metabolism
Correct Answer: D
Rationale: The correct answer is D: Altered nutrient metabolism. Immobility can lead to changes in nutrient metabolism due to decreased physical activity and muscle mass. The body may start breaking down muscle tissue for energy, leading to altered nutrient metabolism.
A: Increased appetite is not directly related to immobility and is unlikely to be a metabolic alteration seen in this patient.
B: Increased diarrhea is more likely related to gastrointestinal issues rather than a direct metabolic alteration due to immobility.
C: Increased metabolic rate is unlikely in an immobile patient as physical activity is decreased.
Therefore, D is the correct choice as it directly relates to the metabolic changes associated with immobility.
Nurse educator is discussing facility protocol for tornados with staff. Which should nurse include in instructions? (Select all that apply.)
- A. Open doors to client rooms
- B. Place blankets over clients who are confined to beds
- C. Move beds away from windows
- D. Draw shades & close drapes
- E. Relocate ambulatory clients in hallways back to rooms
Correct Answer: B,C,D
Rationale: The correct answers are B, C, and D. Placing blankets over clients in beds provides protection from debris. Moving beds away from windows minimizes the risk of glass injuries. Drawing shades and closing drapes can prevent glass shards from entering the room. Opening doors to client rooms (A) is incorrect as it can create a draft and increase the risk of injury. Relocating ambulatory clients back to rooms (E) is unnecessary if they are safe in hallways. Choices F and G are not provided in the question. In summary, the correct instructions focus on protecting clients from debris and glass injuries during a tornado.