Nokea
A client is admitted to a mental health unit with a diagnosis of anorexia nervosa. When planning care for this client, which primary intervention should health promotion focus on?
- A. Providing a supportive environment
- B. Examining intrapsychic conflicts and past issues
- C. Emphasizing social interaction with clients who are withdrawn
- D. Helping the client identify and examine dysfunctional thoughts and beliefs
Correct Answer: D
Rationale: Health promotion focuses on helping clients identify and examine dysfunctional thoughts, as well as identifying and examining the values and beliefs that maintain these thoughts. Providing a supportive environment is important, but it is not as primary as option 4 for this client. Examining intrapsychic conflicts and past issues is not directly related to the client's problem. Emphasizing social interaction is not appropriate at this time.
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The nurse is creating a plan of care for a newborn diagnosed with bilateral club feet. Which information should the nurse plan to include in the parents education?
- A. The regimen of manipulation and casting is effective in all cases of bilateral club feet.
- B. Genetic testing is wise for future pregnancies because other children born to this couple may also be affected.
- C. If casting is needed, it will begin at birth and continue for 12 weeks, at which time the condition will be reevaluated.
- D. Surgery performed immediately after birth has been found to be the most effective for achieving a complete recovery.
Correct Answer: C
Rationale: For the infant with clubfoot, casting should begin at birth and continue for at least 12 weeks or until maximum correction is achieved. At this time, corrective shoes may provide support to maintain alignment, or surgery can be performed. Surgery is usually delayed until the child is 4 to 12 months old. Options 1 and 4 are inaccurate. Option 2 does not specifically address the subject of the question.
The home care nurse is preparing a plan of care for a client diagnosed with Ménière's syndrome. Which nursing intervention should the nurse include to assist the client with controlling vertigo?
- A. Instruct the client to cut down on cigarette smoking.
- B. Encourage the client to increase the daily fluid intake.
- C. Encourage the client to avoid sudden head movements.
- D. Instruct the client to increase the amount of sodium in the diet.
Correct Answer: C
Rationale: Ménière's syndrome refers to dilation of the endolymphatic system by overproduction or decreased resorption of endolymphatic fluid. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Clients are advised to stop smoking because of its vasoconstrictive effects. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed.
The school nurse is preparing to perform health screening for scoliosis on children aged 9 through 14. Which instruction should the nurse plan to provide to the children?
- A. Lie flat and lift the legs straight up.
- B. Lie on the right side and then roll to the left side while the arms are held overhead.
- C. Walk 10 feet forward and then 10 feet backward with the arms held overhead at both sides.
- D. Stand with weight equally on both feet with the legs straight, and the arms hanging loosely at both sides.
Correct Answer: D
Rationale: To perform this screening test, the child should be asked to disrobe or wear underpants only so that the chest, back, and hips can be clearly seen. The child is asked to stand with weight equally on both feet with the legs straight and the arms hanging loosely at both sides. The nurse assesses the child's posture, spinal column, shoulder height, and leg lengths. Lying down positions and walking forward and backward are incorrect assessment techniques.
The nurse is preparing to assist in the administration of a chemotherapeutic agent via intraperitoneal (IP) therapy. In which position should the nurse plan to place the client before administering this therapy?
- A. Supine
- B. Semi-Fowler's
- C. Trendelenburg's
- D. Dorsal recumbent
Correct Answer: B
Rationale: IP therapy is the administration of chemotherapeutic agents into the peritoneal cavity. This therapy is used for intra-abdominal malignancies such as ovarian and gastrointestinal tumors that have moved into the peritoneum after surgery. The client should be placed in a semi-Fowler's position for this infusion because the client may experience nausea and vomiting caused by increasing pressure on the internal organs. Additionally, this treatment may also place pressure on the diaphragm. The positions indicated in the rest of the options would increase pressure in the peritoneal cavity.
The nurse is receiving a client from the emergency department who has a diagnosis of Guillain-Barré syndrome. The client's chief sign/symptom is an ascending paralysis that has reached the level of the waist. Which items should the nurse plan to have available for emergency use?
- A. Nebulizer and pulse oximeter
- B. Blood pressure cuff and flashlight
- C. Flashlight and incentive spirometer
- D. Cardiac monitor and intubation tray
Correct Answer: D
Rationale: The client with Guillain-Barré syndrome is at risk for respiratory failure as a result of ascending paralysis. An intubation tray should be available for emergency use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the need for cardiac monitoring. Although some of the items in the remaining options may be kept at the bedside (e.g., pulse oximeter, blood pressure cuff, flashlight), they are not necessarily needed for emergency use in this situation.