Nokea
A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be:
- A. Accepting her present body image
- B. Verbalizing realistic feelings about her body
- C. Having an improved perception of her body image
- D. Exhibiting increased self-esteem
Correct Answer: B
Rationale: This outcome criterion is inadequate because the term 'accepts' is not directly measurable. This outcome criterion is directly measurable because specific goal-related verbalizations can be heard and verified by the nurse. 'Improved perception of body image' is not directly measurable and is therefore open to many interpretations. Although long-term goals for the anorexic client should focus on increased self-esteem, this outcome criterion (as stated) does not include specific indicators or behaviors for which to observe.
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The home care nurse is preparing a teaching plan for a client with deficiencies in folic acid. Which foods will increase the clients' folic acid level?
- A. Broccoli
- B. Cabbage
- C. Chicken
- D. Dried fruit
- E. White bread
- F. Milk
Correct Answer: A, B, D
Rationale: Folic acid-rich foods include broccoli (A), cabbage (B), and dried fruit (D). Chicken (C), white bread (E), and milk (F) are low in folate.
The orthopedic nurse should be particularly alert for a fat embolus in which of the following clients having the greatest risk for this complication after a fracture?
- A. A 50-year-old with a fractured fibula
- B. A 20-year-old female with a wrist fracture
- C. A 21-year-old male with a fractured femur
- D. An 8-year-old with a fractured arm
Correct Answer: C
Rationale: Fat embolus is most common in long bone fractures, especially the femur, and in young adults. A 21-year-old with a femur fracture (C) is at highest risk. Fibula (A), wrist (B), and arm (D) fractures have lower risk.
A child is admitted with severe headache, fever, vomiting, photophobia, drowsiness, and stiff neck associated with viral meningitis. She will be more comfortable if the nurse:
- A. Dims the lights in her room
- B. Encourages her to breathe slowly and deeply
- C. Offers sips of warm liquids
- D. Places a large, soft pillow under her head
Correct Answer: A
Rationale: The discomfort of photophobia is alleviated by dimming the lights. Helping the child to breathe slowly and deeply may help to reduce anxiety, but it will not alleviate other discomforts of viral meningitis. It is important to maintain fluid balance, but sips of warm liquids do not alleviate the discomforts of meningitis. A large, soft pillow under her head causing neck flexion is likely to increase her discomfort owing to stretching of the meninges.
The client is diagnosed with hyperkalemia. Which food should the nurse instruct the client to avoid?
- A. Bananas
- B. Broccoli
- C. Salmon
- D. Pasta
Correct Answer: A
Rationale: Bananas are high in potassium, which should be avoided in hyperkalemia to prevent worsening arrhythmias. Broccoli, salmon, and pasta have lower potassium content.
A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5'4'' and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:
- A. Obtain an accurate weight
- B. Search the client's purse for pills
- C. Assess vital signs
- D. Assign her to a room with someone her own age
Correct Answer: C
Rationale: Vital signs are a high priority when working with self-destructive clients.