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A nurse is developing a plan of care for a client who has anorexia nervosa. Which of the following actions should the nurse include in the plan?
- A. Encourage the client to participate in developing a system of rewards.
- B. Arrange for someone to remain with the client for 30 minutes after meals.
- C. Offer the client a selection of beverages at each meal.
- D. Inform the client that a weight gain of 2.3 kg per week is expected.
Correct Answer: A
Rationale: Encouraging the client to participate in developing a system of rewards is an essential part of the plan of care for a client with anorexia nervosa. This action can help motivate and engage the client in their treatment plan, promoting a sense of achievement and progress. Choice B, arranging for someone to remain with the client for 30 minutes after meals, may not address the underlying issues related to anorexia nervosa and could potentially disrupt the client's independence. Choice C, offering a selection of beverages at each meal, is not directly related to addressing the client's condition of anorexia nervosa. Choice D, informing the client about an expected weight gain, could increase anxiety and may not be appropriate without considering the client's individual progress and readiness.
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A healthcare professional is preparing to remove a client's clogged NG tube prior to re-inserting a new tube. Which of the following actions should the healthcare professional take first?
- A. Assist the client in blowing their nose.
- B. Ask the client to take a deep breath and hold it.
- C. Pinch the proximal end of the tube.
- D. Disconnect the tube from the suction source.
Correct Answer: D
Rationale: Correct Answer: Disconnecting the tube from the suction source is the first step in safely removing a clogged NG tube. This action helps prevent any suction-related complications and ensures a smooth transition when removing the tube. Choice A, assisting the client to blow their nose, is not necessary in this situation. Choice B, asking the client to take a deep breath and hold it, is unrelated to the process of removing a clogged NG tube. Choice C, pinching the proximal end of the tube, should only be done after disconnecting the tube from the suction source to prevent the contents from leaking.
A client is being taught by a nurse about adding more fiber to the diet. Which of the following foods has the highest fiber content?
- A. 1 cup cooked sweet potato
- B. 1 slice rye toast
- C. 1 cup raw watermelon
- D. 1 oz cashews
Correct Answer: D
Rationale: The correct answer is D, 1 oz of cashews. Cashews have a higher fiber content compared to sweet potato, rye toast, and watermelon. While sweet potatoes and rye toast contain fiber, cashews have a higher concentration, making them a better choice for increasing fiber intake. Watermelon, on the other hand, is low in fiber compared to the other options provided.
A nurse is providing teaching to an obese client who has gestational diabetes and is at 25 weeks of gestation. Which of the following statements made by the client indicates a need for further teaching?
- A. This does not mean that my baby will have this disease.
- B. This means that I will have diabetes for the rest of my life.
- C. If I feel dizzy, I should drink six ounces of a non-diet soda.
- D. Being obese might be one reason why I developed diabetes.
Correct Answer: B
Rationale: The statement 'This means that I will have diabetes for the rest of my life' indicates a need for further teaching. Gestational diabetes often resolves after pregnancy, although it does indicate a higher risk for developing type 2 diabetes in the future. The other choices are correct or provide appropriate information: A) Understanding that gestational diabetes does not mean the baby will have the disease is accurate. C) Advising to drink non-diet soda if feeling dizzy is incorrect and potentially harmful due to the sugar content. D) Recognizing that obesity can be a risk factor for developing diabetes is a valid statement.
A caregiver is teaching a parent about recommended protein intake for a toddler. Which of the following food selections is equivalent to 1 oz of protein?
- A. 2 tbsp peanut butter
- B. ½ cup peas
- C. 1 slice of bread
- D. 1 scrambled egg
Correct Answer: D
Rationale: One scrambled egg is equivalent to 1 oz of protein, making it a suitable choice for a toddler's diet. A ½ cup of peas (choice B) does not provide 1 oz of protein but is still a good source of protein. 2 tbsp of peanut butter (choice A) contains more than 1 oz of protein. 1 slice of bread (choice C) typically provides less protein than 1 oz.
A nurse is reviewing the medication administration record for a client who is 2 days postoperative following abdominal surgery. The nurse should recognize that which of the following medications places the client at risk for wound dehiscence?
- A. Omeprazole
- B. Zolmitriptan
- C. Prednisone
- D. Verapamil
Correct Answer: C
Rationale: Corrected Rationale: Prednisone is a corticosteroid that can impair wound healing and increase the risk of wound dehiscence. Omeprazole (Choice A) is a proton pump inhibitor used to reduce stomach acid production and does not directly impact wound healing. Zolmitriptan (Choice B) is a medication used to treat migraines and does not affect wound healing. Verapamil (Choice D) is a calcium channel blocker used to treat high blood pressure and certain heart conditions, and it does not pose a significant risk for wound dehiscence.