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A nurse weighs a person who has been diagnosed with a dysfunction in the nutritional-metabolic pattern. Which aspect of the nursing process is being performed?
- A. Assessment
- B. Implementation
- C. Planning
- D. Evaluation
Correct Answer: D
Rationale: Weighing the person to assess progress toward goals is part of the evaluation phase of nursing care.
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Which of the following actions should be taken when a 32-year-old woman with malaise is suspected of experiencing achievement-oriented stress?
- A. Sleeping 10 hours per day
- B. Unintentional loss of 10 pounds in the past 3 weeks
- C. Expressed fear of company layoffs
- D. Calling in sick once every 2 weeks for the past month
Correct Answer: B
Rationale: Weight loss, a common sign of achievement-oriented stress, typically occurs due to neglect of health while focusing on career.
When assessing a person’s nutritional-metabolic pattern, which objective finding would have implications for nursing intervention?
- A. The person’s 24-hour diet diary
- B. The person’s dentition
- C. The person’s food preferences
- D. The person’s financial status
Correct Answer: B
Rationale: Dentition is an objective measure, which can be validated during a physical exam and influences nutritional care.
An 18-month-old toddler is being seen for a well-child visit. Which of the following strategies would the nurse use to enlist the toddler’s cooperation?
- A. Ask the toddler if he wants to be examined today.
- B. Ask his mother leave the room while the nurse examines him.
- C. Have him hold the stethoscope diaphragm on his chest while the nurse listens to his chest.
- D. Have his mother hold him down while the nurse examines him.
Correct Answer: C
Rationale: Toddlers are more cooperative when they can actively participate, like holding the stethoscope.
A nurse in a college health center is preparing a program on meningococcal disease. What information should be included?
- A. Living in the dorm increases one’s risk of developing meningococcal disease.
- B. The mortality rate from meningococcal disease is very low.
- C. There are no antiviral medications to treat meningococcal outbreaks.
- D. A vaccine for meningococcal disease has not been developed.
Correct Answer: A
Rationale: Dorm living increases the risk for meningococcal disease, and a vaccine is available for prevention.
During a well-child visit, a father tells the nurse that the preschool-aged child has been enjoying their “road trips” that they take together when the child gets to sit in the front seat of the car with him. Which of the following actions should the nurse take next?
- A. Report the father to the Department of Human Services.
- B. Encourage the father to have the child sit in the back seat instead.
- C. Instruct the father on the dangers of having small children in the front seat.
- D. Provide the parent with educational materials about car seat safety.
Correct Answer: C
Rationale: Children under age 13 should sit in the back seat to avoid injury from airbags in the front seat.