Nokea
A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time?
- A. Small, frequent feedings of foods that can be carried
- B. Tube feedings with nutritional supplements
- C. Allowing him to eat when and what he wants
- D. Giving him a quiet place where he can sit down to eat meals
Correct Answer: A
Rationale: The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with finger foods allow him to eat during periods of activity. This type of therapy should be implemented when other methods have been exhausted. The manic client should not be in control of his treatment plan. This type of client may forget to eat. The manic client is unable to sit down to eat full meals.
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A burn victim's immunization history is assessed by the nurse. Which immunization is of priority concern?
- A. Oral poliovirus vaccine
- B. Inactivated poliovirus vaccine
- C. Tetanus toxoid
- D. Hepatitis B vaccine
Correct Answer: C
Rationale: Tetanus toxoid prevents tetanus. Tetanus is transmitted through contaminated wounds.
A client who has been diagnosed with anorexia nervosa refuses to eat lunch. The most therapeutic response by the nurse to her refusal is:
- A. Okay, missing one meal won't hurt.'
- B. You'll have to eat lunch, or we'll force-feed you.'
- C. It's not appropriate for you to try to manipulate the staff into granting your wishes.'
- D. We will not allow you to starve yourself. You may choose to eat voluntarily or be fed.'
Correct Answer: D
Rationale: Setting limits assures the client that staff has genuine concern for her safety and well-being. Giving her an actual choice will give the client an increased sense of control over her life and avoid an argument or power struggle.
The nurse is caring for a client post-colonoscopy. Which finding requires immediate intervention?
- A. Mild abdominal cramping
- B. Bright red blood in the stool
- C. Slight drowsiness
- D. Flatulence
Correct Answer: B
Rationale: Bright red blood in the stool suggests post-colonoscopy bleeding, possibly from perforation, requiring immediate intervention. Cramping (A), drowsiness (C), and flatulence (D) are expected.
A client with asthma has an order to begin an aminophylline IV infusion. Which piece of equipment is essential for the nurse to safely administer the medication?
- A. Large bore intravenous catheter
- B. IV inline filter
- C. IV infusion device
- D. Cover to prevent exposure of solution to light
Correct Answer: C
Rationale: An IV infusion device ensures precise delivery of aminophylline, preventing toxicity. A large bore catheter (A) is unnecessary, an inline filter (B) is not required, and light protection (D) is not needed for aminophylline.
A client with a history of a thyroidectomy is receiving Calcitonin (Miacalcin). The nurse should monitor the client for:
- A. Hypocalcemia
- B. Hyperglycemia
- C. Hypotension
- D. Weight gain
Correct Answer: A
Rationale: Calcitonin lowers serum calcium, risking hypocalcemia, requiring monitoring for symptoms like tingling. Hyperglycemia, hypotension, and weight gain are not primary concerns.