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Nurse reviewing nutrition guidelines with parents of 11 yo. Which parent statement should indicate to nurse that they understand guidelines for school-age children?
- A. She wants to eat as much as us, but we're afraid she'll be overweight.
- B. She skips lunch sometimes but we figure it's okay as long as she has healthy breakfast & dinner.
- C. We limit fast food restaurant meals to 3x/week now
- D. We reward her school achievements with point system instead of pizza or ice cream
Correct Answer: D
Rationale: The correct answer is D because it demonstrates understanding of the guidelines by promoting non-food rewards for school achievements, which helps instill healthy habits and a positive relationship with food. This approach encourages the child to associate success with non-food rewards, fostering a healthy attitude towards food and eating habits. Choices A, B, and C focus on the child's weight, meal skipping, and fast food consumption, which are not aligned with the guidelines for school-age children. These choices may promote unhealthy eating behaviors or weight concerns.
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Nurse reviewing CDC's immunizations recommendations with middle adult. Which should nurse include in this discussion? (Select all that apply.)
- A. Haemophilus influenzae type b
- B. Varicella
- C. Herpes zoster
- D. HPV
- E. Seasonal influenza
Correct Answer: B,C,E
Rationale: The correct choices for the nurse to include in the discussion with the middle adult are Varicella, Herpes zoster, and Seasonal influenza. Varicella (chickenpox) and Herpes zoster (shingles) are important vaccinations to prevent these viral infections, especially in middle-aged adults who may be at higher risk. Seasonal influenza vaccination is also crucial for middle adults to protect against flu-related complications. Haemophilus influenzae type b is typically given to children under 5, so it is not relevant for this age group. HPV vaccination is recommended for younger individuals to prevent certain cancers.
Nursing instructor explaining various stages of lifespan to students. Nurse should offer which following behavior by young adult as example of appropriate psychosocial development?
- A. Becoming actively involved in providing guidance to next generation
- B. Adjusting to major changes in roles/relationships due to losses
- C. Devoting great deal of time to establishing occupation
- D. Finding oneself 'sandwiched' between being responsible for 2 generations
Correct Answer: C
Rationale: The correct answer is C because in young adulthood, individuals typically focus on establishing their careers and developing a sense of identity. This behavior aligns with Erikson's psychosocial stage of intimacy vs. isolation. Choices A, B, and D are incorrect for a young adult's appropriate psychosocial development. A focuses on generativity, which is more typical of middle adulthood. B suggests dealing with losses, which is more aligned with later stages of life. D describes the 'sandwich generation' phenomenon, which occurs later in life when individuals are responsible for both their children and aging parents.
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 caring for client just admitted after falling. This client is oriented x3 & can follow directions. Which action(s) by nurse are appropriate to decrease risk of fall? (Select all that apply)
- A. Place belt restraint on him when he's sitting on bedside commode
- B. Keep bed in low position with full side rails up
- C. Ensure client's call light is within reach
- D. Provide client with nonskid footwear
- E. Complete fall-risk assessment
Correct Answer: C,D,E
Rationale: Correct Answer: C, D, E
Rationale:
C: Ensuring client's call light is within reach allows the client to easily call for assistance, reducing the risk of attempting to get up independently and potentially falling.
D: Providing the client with nonskid footwear increases traction and stability, reducing the risk of slipping and falling.
E: Completing a fall-risk assessment helps identify specific factors contributing to the client's risk of falling, allowing for tailored interventions to prevent falls.
Incorrect Choices:
A: Placing a belt restraint on the client when he's on the bedside commode is inappropriate as it restricts movement and can lead to increased agitation or attempts to remove the restraint, potentially causing a fall.
B: Keeping the bed in a low position with full side rails up can actually increase the risk of injury in case of a fall, as the client may try to climb over the rails or could become trapped between the rails and the bed.
A home health nurse is discussing dangers of carbon monoxide poisoning with a client. What information should the nurse include?
- A. Carbon monoxide has a distinct odor
- B. Water heaters should be inspected every 5 years
- C. Lungs are damaged from carbon monoxide inhalation
- D. Carbon monoxide binds with hemoglobin in body
Correct Answer: D
Rationale: The correct answer is D: Carbon monoxide binds with hemoglobin in the body. This is correct because carbon monoxide binds with hemoglobin in the blood more easily than oxygen, leading to decreased oxygen delivery to tissues. This can result in symptoms of carbon monoxide poisoning.
A: Carbon monoxide is odorless, so this is incorrect.
B: While regular inspection of appliances like water heaters is important for safety, it is not directly related to carbon monoxide poisoning.
C: Carbon monoxide primarily affects the body by interfering with oxygen transport, not by directly damaging the lungs.
In summary, choice D is correct because it explains the mechanism of carbon monoxide poisoning, while the other choices are incorrect as they do not directly relate to the dangers of carbon monoxide poisoning.