Nokea
A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following client goals the priority?
- A. Identify changes within the family unit that promote the client's autonomy.
- B. Gain 2 pounds of weight per week.
- C. Make positive statements about improvements in body image.
- D. Feel in control of her behavior.
Correct Answer: B
Rationale: The correct answer is B: Gain 2 pounds of weight per week. In anorexia nervosa, the primary goal is to restore the client's weight to a healthy level to prevent serious health complications. Weight restoration is crucial in addressing the physical consequences of severe malnutrition and improving overall health. Gaining weight at a steady pace of 2 pounds per week is a realistic and safe goal.
Other choices are incorrect because:
A: Identifying changes within the family unit is important but not the priority compared to addressing the physical health concerns.
C: Making positive statements about improvements in body image is important for psychological well-being but does not address the immediate health risks associated with anorexia.
D: Feeling in control of behavior is a valid goal, but weight restoration takes precedence due to the critical nature of the client's physical health in anorexia nervosa.
You may also like to solve these questions
A charge nurse is evaluating the performance of an assistive personnel (AP). Which of the following actions by the AP indicates a need for further education?
- A. The AP reports a client's temperature of 38.5°C to the nurse.
- B. The AP assists a client with turning every 2 hours.
- C. The AP leaves a client's meal tray out of reach after delivery.
- D. The AP uses a gait belt when ambulating a client.
Correct Answer: C
Rationale: Leaving the meal tray out of reach prevents the client from eating, indicating a need for further education on client-centered care. The other actions are appropriate.
A nurse in an emergency department receives report from an emergency responder who states a client is being transported following exposure to a 'dirty bomb'. The nurse should prepare to care for a client that has been exposed to which of the following types of agents?
- A. Radiologic
- B. Anthrax
- C. Chemical
- D. Sarin
Correct Answer: A
Rationale: The correct answer is A: Radiologic. A 'dirty bomb' combines conventional explosives with radioactive material, leading to radiologic exposure. The emergency responder's report of a 'dirty bomb' indicates potential radiation exposure. Choice B, Anthrax, is incorrect as it is a biological agent. Choice C, Chemical, is incorrect as it refers to exposure to toxic chemicals. Choice D, Sarin, is incorrect as it is a nerve agent. In summary, the nurse should prepare for radiologic exposure due to the 'dirty bomb' incident.
A charge nurse is orienting a newly licensed nurse to the unit's emergency response procedures. Which of the following statements by the newly licensed nurse indicates a need for further teaching?
- A. I should pull the fire alarm if I see smoke in a client's room.
- B. I need to know the location of the nearest fire extinguisher.
- C. I can use an elevator to evacuate clients during a fire.
- D. I should close all doors to contain a fire on the unit.
Correct Answer: C
Rationale: Using an elevator during a fire is unsafe due to the risk of entrapment or power failure, indicating a need for further teaching. The other statements reflect correct fire safety protocols.
A nurse is discussing emergency response with a newly licensed nurse. The nurse should identify which of the following as a triage officer during the time of a disaster?
- A. Nurses and other emergency medical personnel
- B. Responding law enforcement officers
- C. Members of the Federal Emergency Management Agency (FEMA)
- D. Representatives from the American Red Cross
Correct Answer: A
Rationale: The correct answer is A because nurses and other emergency medical personnel are trained to assess and prioritize patients based on their medical needs during a disaster. They have the expertise to quickly identify and categorize patients to ensure those with the most critical conditions receive immediate care. Responding law enforcement officers (B) focus on security and crowd control. Members of FEMA (C) are responsible for coordinating disaster response at a larger scale. Representatives from the American Red Cross (D) provide support services but do not typically serve as triage officers.
A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first?
- A. An infant who has pertussis and is receiving oxygen via nasal cannula
- B. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions
- C. A school-age child who has diabetes mellitus and requires blood glucose monitoring
- D. A toddler who has both arms in casts and needs to be fed his breakfast
Correct Answer: A
Rationale: The correct answer is A. The nurse should assess the infant with pertussis receiving oxygen first because pertussis can cause severe respiratory distress. Assessing the infant's respiratory status is crucial as pertussis can lead to respiratory failure. Oxygen therapy is essential for maintaining adequate oxygenation levels. The nurse must monitor the infant's respiratory rate, effort, and oxygen saturation levels to ensure proper oxygenation. This assessment takes priority over the other clients' needs.
Choice B is incorrect because although the adolescent has sickle cell crisis, they are stable and ready for discharge instructions, which can be addressed after the critical assessment of the infant is completed.
Choice C is incorrect as monitoring blood glucose levels in a child with diabetes is important but does not take precedence over assessing a critically ill infant with pertussis.
Choice D is incorrect as feeding a toddler with both arms in casts can be challenging but does not pose an immediate threat to their health compared to the infant with pertussis requiring oxygen.
In