Nokea
A two year-old child is brought to the provider's office with a chief complaint of mild diarrhea for two days. Nutritional counseling by the nurse should include which statement?
- A. Place the child on clear liquids and gelatin for 24 hours
- B. Continue with the regular diet and include oral rehydration fluids
- C. Give bananas, apples, rice and toast as tolerated
- D. Place NPO for 24 hours, then rehydrate with milk and water
Correct Answer: B
Rationale: Current recommendations for mild to moderate diarrhea are to maintain a normal diet with fluids to rehydrate.
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A high school nurse observes a 14 year-old female rubbing her scalp excessively in the gym. The most appropriate course of action for the nurse to do is:
- A. Request a private evaluation of the female's scalp from her parents.
- B. Contact the female's parents about the observations.
- C. Observe the hairline and scalp for possible signs of lice.
- D. Contact the student's physician.
Correct Answer: C
Rationale: Observation of the student's hair is the next step.
The doctor has ordered nasogastric feedings for an elderly client with dysphagia. Prior to administering a tube feeding, the nurse should:
- A. Discard any aspirant and begin the tube feeding.
- B. Check the pH of the aspirant.
- C. Connect the tubing to suction.
- D. Mix the feeding with 200 mL of water.
Correct Answer: B
Rationale: Checking the pH of gastric aspirant confirms tube placement in the stomach (pH <5). Discarding aspirant risks fluid loss, suction is not routine, and mixing with water dilutes the feeding.
A male client is admitted with urinary tract problems. A prostate-specific antigen (PSA) and acid phosphatase Test are to be done.
The nurse knows that
- A. these Test s are valuable screening Test s for prostatic cancer.
- B. the level of PSA is decreased in clients with renal stones.
- C. the level reflects the level of renal involvement in acid-base problems.
- D. the level of PSA is elevated in clients in early stage renal failure.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-PSA Test has replaced acid phosphatase Test in screening for prostatic cancer; Test must be drawn before digital rectal exam, as manipulation of the prostate will abnormally increase PSA value (2) inaccurate information about a PSA (3) inaccurate information about a PSA (4) inaccurate information about a PSA
The nurse is caring for a client with a history of bipolar disorder who is receiving lithium 300 mg PO tid. Which of the following symptoms should the nurse report immediately?
- A. Mild thirst.
- B. Tremors and confusion.
- C. Occasional diarrhea.
- D. Dry mouth.
Correct Answer: B
Rationale: Tremors and confusion suggest lithium toxicity, a medical emergency. Options A, C, and D are common side effects.
A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to
- A. Convince the client that the hospital staff is trying to help
- B. Help the client to enter into group recreational activities
- C. Provide interactions to help the client learn to trust staff
- D. Arrange the environment to limit the client's contact with other clients
Correct Answer: C
Rationale: Provide interactions to help the client learn to trust staff. Establishing trust helps clients feel safer and facilitates a therapeutic alliance between staff and client.