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Assessment findings the nurse could expect to find in the infant with biliary atresia are:
- A. Excessive drooling that requires frequent suctioning
- B. Pale, frothy stools, and poor weight gain
- C. Poor tissue turgor and weight loss
- D. Clay-colored stools and abdominal distention
Correct Answer: D
Rationale: Biliary atresia causes bile duct obstruction, leading to clay-colored stools and abdominal distention from liver enlargement, so D is correct. Answers A, B, and C are not specific to biliary atresia.
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An adult client became incontinent while hospitalized. The client now drinks very little. The nurse understands that this is:
- A. a coping strategy.
- B. a defense mechanism.
- C. a way to not bother the nurse.
- D. regression.
Correct Answer: A
Rationale: Reduced fluid intake is a coping strategy to avoid incontinence, though it risks dehydration, reflecting an attempt to manage embarrassment.
The nurse is the leader of a group of mentally retarded adults. The nurse instructs the group members to ignore another client whenever he interrupts others who are speaking. To evaluate the progress of this intervention, the nurse should
- A. measure improvement by counting the number of times the client succeeds.
- B. measure improvement by counting the number of interruptions.
- C. assess the ability of the group to control the client’s interruptions.
- D. count the number of tokens and earned privileges given for interruptions.
Correct Answer: A
Rationale: Counting successful non-interruptions measures the client’s behavioral improvement, the goal of the intervention. Options B, C, and D are less effective: counting interruptions tracks failures, group control is secondary, and tokens are not given for interruptions.
A client is scheduled to have a blood test for cholesterol and triglycerides the next day. The nurse would tell the client
- A. Be sure and eat a fat-free diet until the test.'
- B. Do not eat or drink anything but water for 12 hours before the blood test.'
- C. Have the blood drawn within 2 hours of eating breakfast.'
- D. Stay at the laboratory so 2 blood samples can be drawn an hour apart.'
Correct Answer: B
Rationale: Do not eat or drink anything but water for 12 hours before the blood test.' Blood lipid levels should be measured on a fasting sample.
The nurse is teaching a community group about healthy lifestyles to prevent cancer and heart disease. Which comment by a member of the group indicates a need for more teaching?
- A. Smoking is not good for you.'
- B. Reducing fat intake helps reduce the risk of heart disease.'
- C. Walking every day puts a strain on your heart.'
- D. Eating lots of fruits and vegetables helps keep me healthy.'
Correct Answer: C
Rationale: Daily walking strengthens the heart, reducing cardiovascular risk, not straining it. The other statements align with healthy lifestyle practices.
A child who received meperidine (Demerol) IM one hour ago.
The nurse knows that which of the following is the BEST assessment indicating relief from abdominal pain for a child who received meperidine (Demerol) IM one hour ago?
- A. The child states that his pain has gone away.
- B. The child's heart rate has changed from 80 to 95.
- C. The child sleeps except when receiving nursing care.
- D. Results from the incentive spirometer have improved.
Correct Answer: D
Rationale: Strategy: Think about what the words mean. (1) contains correct information, but is not a priority; child could deny pain out of fear of getting another injection (2) indicates discomfort, anxiety (3) indicates a need to decrease the amount of medication (4) correct-when pain is decreased, child will be better able to breathe deeply and improve the outcome of use of the incentive spirometer