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A 15-year-old adolescent with anorexia nervosa is admitted to the hospital for severe weight loss. The nurse notes that the client has dry skin, brittle hair, and is severely underweight. What is the nurse's priority intervention?
- A. Establish a therapeutic relationship with the client
- B. Monitor the client's vital signs frequently
- C. Initiate a structured eating plan
- D. Provide education about healthy eating habits
Correct Answer: C
Rationale: In this scenario, the priority intervention for the nurse is to initiate a structured eating plan. Anorexia nervosa is a serious eating disorder characterized by severe food restriction, which can lead to malnutrition and severe weight loss. By starting a structured eating plan, the nurse can ensure the client receives the necessary nutrition to begin the process of weight restoration and recovery. Monitoring vital signs is essential, but without addressing the nutrition deficiency, vital signs may not improve significantly. Establishing a therapeutic relationship is crucial for long-term care but may not address the immediate risk of malnutrition. Providing education about healthy eating habits is important but may not be effective initially due to the severity of the client's condition.
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A 10-year-old child is brought to the emergency department after falling from a bicycle and hitting their head. The nurse notes that the child is drowsy and has a headache. What is the nurse's priority action?
- A. Perform a full neurological assessment
- B. Administer pain medication
- C. Allow the child to rest quietly
- D. Check the child's immunization status
Correct Answer: A
Rationale: In a child who has fallen and hit their head, presenting with drowsiness and headache, the priority action for the nurse is to perform a full neurological assessment. This is crucial to evaluate the extent of the head injury and monitor for signs of increased intracranial pressure, which could indicate a more severe traumatic brain injury. Administering pain medication or allowing the child to rest quietly are not appropriate initial actions without first assessing the neurological status. Checking the child's immunization status is important for overall health but is not the priority in this acute situation.
The practical nurse is providing care for a toddler who has just returned from surgery for a tonsillectomy. Which intervention is a priority in the immediate postoperative period?
- A. Offer clear fluids frequently.
- B. Encourage the child to cough and deep breathe.
- C. Monitor for frequent swallowing.
- D. Apply a warm compress to the throat area.
Correct Answer: C
Rationale: Monitoring for frequent swallowing is a priority intervention in the immediate postoperative period after a tonsillectomy. Frequent swallowing may indicate bleeding from the surgical site, which requires immediate attention to prevent complications such as hemorrhage. Offering clear fluids frequently may not be appropriate immediately after surgery. Encouraging coughing and deep breathing may increase the risk of bleeding. Applying a warm compress to the throat area is not recommended as it can increase blood flow to the surgical site, potentially causing bleeding.
A child with cystic fibrosis is being discharged home with pancreatic enzyme replacement therapy. What information should the practical nurse reinforce with the parents?
- A. Give the enzymes after meals.
- B. Mix the enzymes with hot food or drinks.
- C. Enzymes should be taken before or with meals.
- D. Avoid giving enzymes with any food or drink.
Correct Answer: C
Rationale: The correct answer is C: 'Enzymes should be taken before or with meals.' Pancreatic enzymes should be taken before or with meals to assist with digestion in children with cystic fibrosis. This timing helps maximize the effectiveness of the enzymes in breaking down nutrients from food. Giving the enzymes after meals (choice A) may not provide the necessary support for digestion. Mixing the enzymes with hot food or drinks (choice B) is not recommended as it may affect the enzymes' efficacy. Avoiding giving enzymes with any food or drink (choice D) is incorrect as enzymes need to be taken in conjunction with meals to aid in digestion.
The nurse determines that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take?
- A. Document the finding
- B. Palpate scrotum for testicular descent
- C. Assess for bladder distension
- D. Auscultate bowel sounds
Correct Answer: A
Rationale: The correct action for the nurse to take in this situation is to document the finding. The infant voiding a urinary stream from the ventral surface of the penis suggests hypospadias, a condition where the urethral opening is on the underside of the penis. This finding is crucial information that needs to be documented for further evaluation. Palpating the scrotum for testicular descent, assessing for bladder distension, and auscultating bowel sounds are not appropriate actions based on the presented scenario and do not address the specific concern of the urinary stream location.
While teaching a parenting class to new parents, the nurse describes the needs of infants and toddlers regarding discipline and limit setting. What is the most important reason for implementing such parenting behaviors?
- A. Children need help in developing social skills.
- B. This age group fears loss of self-control.
- C. They provide the child with a sense of security.
- D. Children must learn to deal with authority.
Correct Answer: C
Rationale: Implementing discipline and limit setting for infants and toddlers is primarily important as it provides them with a sense of security. This sense of security is crucial for their emotional and psychological development, helping them feel safe and supported as they explore the world around them. Choice A is incorrect because while developing social skills is important, the primary reason for discipline and limit setting in this context is to provide security. Choice B is incorrect as it does not address the main reason for implementing discipline and limit setting. Choice D is incorrect as the primary focus is not about dealing with authority at this early stage of development.