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A nurse is reinforcing teaching with an adolescent client who has a prescription for lisinopril. Which of the following foods should the nurse instruct the client to avoid?
- A. Foods high in fiber
- B. High-potassium foods
- C. Foods high in vitamin K
- D. Dairy products
Correct Answer: B
Rationale: Lisinopril can raise potassium levels, so avoiding high-potassium foods prevents hyperkalemia. Fiber, vitamin K, and dairy are not contraindicated.
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A nurse is caring for an adolescent client who has a terminal illness. Which of the following statements should the nurse make to the parent?
- A. I will administer pain medication on a schedule.
- B. I will limit visits from siblings who are under the age of 18.
- C. You should go home when your child needs to rest.
- D. You should allow your child to die at home.
Correct Answer: A
Rationale: Scheduled pain medication ensures comfort. Limiting sibling visits, dictating parental presence, or suggesting home death disregard family preferences and needs.
A nurse is planning to reinforce teaching about head injuries with a group of parents of school-age children. The nurse should instruct the parents to monitor for and report which of the following manifestations?
- A. Insomnia
- B. Irritability
- C. Diarrhea
- D. Hypothermia
Correct Answer: B
Rationale: Irritability may signal increased intracranial pressure post-head injury, requiring prompt reporting. Insomnia, diarrhea, and hypothermia are less directly related.
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Loosen restrictive clothing.
- B. Hyperextend the child's neck.
- C. Time the seizure episode.
- D. Place the child in a side-lying position.
- E. Restrain the child.
Correct Answer: A,C,D
Rationale: Loosening clothing, timing the seizure, and side-lying position ensure safety and documentation. Hyperextending the neck risks injury, and restraining is unsafe.
A nurse is preparing to percuss an adolescent's chest and abdomen. Which of the following areas should the nurse expect to hear a dull sound?
- A. This region of the chest is expected to be resonant on percussion because of the air in the lung.
- B. The right upper quadrant of the abdomen is usually dull on percussion because of the underlying liver.
- C. This site is tympanic because of the gas in the intestines.
Correct Answer: B
Rationale: The right upper quadrant is dull due to the liver. The chest is resonant, and intestines are tympanic.
A nurse is collecting data from a toddler who has heart failure. Which of the following findings should the nurse expect?
- A. Weight loss of 0.9 kg (2 lb)
- B. Heart rate 65/min
- C. Bounding peripheral pulses
- D. Decreased urine output
Correct Answer: D
Rationale: Decreased urine output is expected in heart failure due to poor renal perfusion. Weight gain, not loss, is typical, and heart rate is usually elevated, not normal. Pulses are often weak.