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Mother of 7 mo infant tells nurse that her baby has been fussy with occasional loose stools since she started feeding him fruits & veggies. Which responses by nurse are appropriate? (Select all that apply.)
- A. It might be good to add bananas, as they help with loose stools
- B. Let's make list of foods he's eating so we can spot problems
- C. Did the changes begin after you started 1 particular food?
- D. Has he been vomiting since he started these new foods?
- E. Most babies react with indigestion when you start new foods
Correct Answer: B,C,D
Rationale: Correct Answer: B, C, D
Rationale:
B: Making a list of foods eaten helps identify potential triggers for fussiness and loose stools.
C: Asking about a specific food can pinpoint the culprit causing the symptoms.
D: Vomiting could indicate a more serious issue, so this question helps assess the severity of the symptoms.
Incorrect Choices:
A: Bananas may not necessarily help with loose stools, and adding more foods could worsen the issue.
E: Making a generalization about how babies react to new foods is not helpful in this specific case.
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Nurse is caring for client with many risk factors for CV disease. When planning health promotion & disease prevention strategies for this client, which intervention should nurse include? (Select all that apply.)
- A. Help client see benefits of her actions
- B. Identify client's support systems
- C. Suggest & recommend community resources
- D. Devise & set goals for client
- E. Teach stress management strategies
Correct Answer: A,B,C,E
Rationale: The correct interventions for the nurse to include are A, B, C, and E. A is correct because helping the client see the benefits of their actions can motivate them to engage in health promotion activities. B is important to identify the client's support systems to provide a strong network for the client. C is crucial to suggest and recommend community resources that can further support the client in maintaining cardiovascular health. E is necessary to teach stress management strategies as stress can impact cardiovascular health. Choices D, F, and G are incorrect because setting goals for the client without their input may not be effective, and leaving options blank does not contribute to the client's care plan.
As part of admission process
- A. nurse at long-term care facility is gathering nutrition history for client with dementia. Which component is priority to determine from their family?
- B. BMI
- C. Usual times for meals/snacks
- D. Favorite foods
- E. Any difficulty swallowing
Correct Answer: D
Rationale: The correct answer is D: Favorite foods. This is because knowing the client's favorite foods is crucial in ensuring they receive proper nutrition and enjoy their meals, especially for someone with dementia who may have difficulty remembering or expressing preferences. It helps enhance their quality of life and promotes adequate food intake.
Other choices are less critical:
A: Nutrition history can include various components, not just family input.
B: BMI is important but not the priority when gathering nutrition information.
C: Knowing meal/snack times is relevant but not as crucial as favorite foods.
E: Swallowing difficulty is important but not the priority in this scenario.
Nurse reviewing CDC's immunization recommendations for young adult. Which should nurse include in this discussion? (Select all that apply.)
- A. HPV
- B. Measles, mumps, rubella
- C. Varicella
- D. Haemophilus influenzae type b
- E. Polio
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C. The nurse should include HPV, measles, mumps, rubella, and varicella in the discussion as these are recommended immunizations for young adults by the CDC. HPV vaccination helps prevent certain types of cancers and genital warts. Measles, mumps, and rubella vaccines protect against highly contagious diseases. Varicella vaccine prevents chickenpox. Choices D, E, F, and G are incorrect. Haemophilus influenzae type b and polio vaccines are typically given during infancy and childhood, not young adulthood. The options F and G are incomplete.
Nurse is caring for newly admitted client with history of falls. What is the priority action by the nurse?
- A. Complete fall-risk assessment
- B. Educate client & family on fall risks
- C. Complete physical assessment
- D. Survey client's belongings
Correct Answer: A
Rationale: The correct answer is A: Complete fall-risk assessment. This is the priority action because it allows the nurse to identify specific risk factors contributing to the client's falls. By completing a fall-risk assessment, the nurse can implement appropriate interventions to prevent future falls. Choice B is incorrect because education should come after assessing the risk factors. Choice C is not the priority as the client's risk for falls needs to be addressed first. Choice D is irrelevant to addressing the immediate safety concern of falls.
Nurse manager is reviewing care of client with seizures with nurses on unit. Which statement by a nurse requires more instruction?
- A. I will place the client on his side
- B. I will go to the nurses' station for assistance
- C. I will administer meds as prescribed
- D. I will be prepared to insert an airway
Correct Answer: B
Rationale: Correct Answer: B - "I will go to the nurses' station for assistance" requires more instruction.
Rationale: Going to the nurses' station may waste crucial time during a seizure. The nurse should stay with the client, ensure a safe environment (A), administer prescribed meds (C), and be prepared to insert an airway (D) if needed. Going to the nurses' station could delay necessary interventions. Placing the client on their side helps prevent aspiration, administering meds is essential for seizure management, and being prepared to insert an airway is crucial in case of respiratory compromise.