Nokea
An adolescent client hospitalized with anorexia nervosa is described by her parents as 'the perfect child.' When planning care for the client, the nurse should:
- A. Allow her to choose what foods she will eat
- B. Provide activities to foster her self-identity
- C. Encourage her to participate in morning exercise
- D. Provide a private room near the nurse's station
Correct Answer: B
Rationale: Activities fostering self-identity address the underlying issues of low self-esteem and perfectionism common in anorexia nervosa.
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The nurse has documented a treatment on the wrong client's record. Which of the following methods of indicating the error is correct?
- A. The nurse draws a straight line through the incorrect entry and writes 'error' above it and initials the correction.
- B. The nurse uses correction fluid to cover the incorrect entry.
- C. The nurse draws multiple lines through the incorrect entry so it is unreadable, writes 'error' above it, and initials the correction.
- D. The nurse leaves the incorrect entry in place, writes 'error' in the margin, and initials and dates the notation.
Correct Answer: A
Rationale: A single line through the error with 'error' written above and initialed (A) maintains transparency while correcting the record. Correction fluid (B) is unacceptable, multiple lines (C) obscure the record, and margin notes (D) are insufficient.
The complete blood count of a client admitted with anemia reveals that the red blood cells are hypochromic and microcytic. The nurse recognizes that the client has:
- A. Aplastic anemia
- B. Iron-deficiency anemia
- C. Pernicious anemia
- D. Hemolytic anemia
Correct Answer: B
Rationale: Hypochromic, microcytic red blood cells are characteristic of iron-deficiency anemia, caused by insufficient iron for hemoglobin synthesis.
A nurse reviewed a client's progress in smoking cessation, praising the client for being successful but suggesting the client might stop having coffee in the morning since that caused an urge to smoke. Following this session, the client appeared upset and complained that the nurse believed she was doing poorly because she wanted a cigarette with her morning coffee. Which type of cognitive distortion is the client exhibiting?
- A. Overgeneralization
- B. Mental filter
- C. All-or-nothing thinking
- D. Magnification
Correct Answer: B
Rationale: Mental filter (B) involves focusing only on the negative (nurse's suggestion) and ignoring praise, leading to the client's misinterpretation.
The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?
- A. BP 90/60
- B. Chest pain
- C. Anxiety
- D. Temp 98.6°F
Correct Answer: B
Rationale: Chest pain is a hallmark of cardiogenic shock due to myocardial infarction, reflecting cardiac ischemia. Anaphylactic shock typically involves allergic symptoms like urticaria or bronchospasm. Low BP, anxiety, and normal temperature are nonspecific.
The nurse is caring for a client who will have a pulmonary function test (PFT) performed as an outpatient following hospital discharge. Which should the nurse include in his teaching on the procedure? Select all that apply.
- A. have a driver accompany the client to the test site
- B. limit activity in the days leading up to the test
- C. remain NPO after midnight the day before the test
- D. do not smoke for at least 6-8 hours before the test
- E. withhold bronchodilators for 4-6 hours prior to the test
- F. increase aerobic activity as much as possible in the days before the test
Correct Answer: D,E
Rationale: Smoking cessation for 6-8 hours and withholding bronchodilators for 4-6 hours ensure accurate PFT results. Other instructions are unnecessary or incorrect.