Nokea
An 18-year-old client with anorexia nervosa is admitted to the hospital.
In planning to care for the client, the nurse would expect the client to
- A. view her appearance as 'skinny.'
- B. be hypoactive and withdrawn.
- C. want to talk about and plan her meals.
- D. have a close relationship with her mother.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to anorexia. (1) usually view their appearance as fat (2) inaccurate for client with anorexia nervosa (3) correct-display a marked preoccupation with food (4) inaccurate for client with anorexia nervosa
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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.
A client with acute glomerulonephritis requests a snack. Which snack is suitable given the client's dietary restrictions?
- A. Orange
- B. Banana
- C. Applesauce
- D. Raisins
Correct Answer: C
Rationale: Applesauce is a suitable snack for the client with acute glomerulonephritis. Answers A, B, and D are incorrect because oranges, bananas, and dried fruits such as raisins are high in potassium, which is restricted in the diet of the client with AGN.
A client with diabetes experiences Somogyi's effect. To prevent this complication, the nurse should instruct the client to:
- A. Take his insulin each day at 1400 hours
- B. Engage in physical activity daily
- C. Increase the amount of regular insulin
- D. Eat a protein and carbohydrate snack at bedtime
Correct Answer: D
Rationale: Somogyi's effect involves rebound hyperglycemia due to nighttime hypoglycemia. A bedtime snack with protein and carbohydrates prevents hypoglycemia. Options A, B, and C do not directly address this issue.
A 2-month-old boy with a temperature of $102°F (39°C) is brought to the emergency department by his mother.
- A. What should the nurse’s response be based on regarding a fever in a 2-month-old one week after a DPT immunization?
- B. If a fever does occur in a child after a DPT, it usually occurs within the first 2 hours.
- C. An elevated temperature is very rarely seen in a child after a DPT immunization.
- D. If there is a fever after a DPT, it is usually low-grade and appears within the first 48 hours.
- E. The child’s high fever is a direct response to the DPT immunization and should be treated.
Correct Answer: C
Rationale: A low-grade fever within 24-48 hours is a common response to DPT immunization. A high fever (102°F) one week later is unlikely related to the immunization and should be reported to a physician for evaluation, possibly indicating another cause.
A ten-year-old child with leukemia has a large burn on her arm and the burn appears to be oily. The client states that she touched a hot pan, and her mother put cooking fat on it so it would not blister.
The nurse should
- A. document the findings in the chart.
- B. call the physician immediately to report the injury.
- C. teach the client that oil holds germs and makes infection more likely.
- D. wash the burn with soap and water to remove the oil.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the immediate problem of cleansing the wound (2) unnecessary (3) does not address the immediate problem of cleansing the wound (4) correct-because leukemic clients are immunosuppressed, they are more susceptible to infections; cooking fat applied to an open wound increases the possibility of infection; burns should be rinsed immediately with tap water to reduce the heat in the burn