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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 transferring client from acute-care hospital to rehab facility. Which of following info about client should nurse include in transfer report?
- A. Alert & oriented
- B. Refuses to eat spinach
- C. Has shellfish allergy
- D. Requests morphine every 4h
- E. Misses the 2 cats he has at home
- F. allergies
- G. Alertness
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. A - Being alert and oriented is crucial for the client's safety and care continuity. C - Shellfish allergy is critical to prevent adverse reactions. D - Morphine request indicates pain management needs. Incorrect choices: B - Food preference is not a priority in transfer report. E - Missing pets is not pertinent medical information. F, G - General terms without specific details are not essential for transfer report.
Nurse counseling young adult who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention?
- A. I have my own apartment now, but it's not easy living away from my parents
- B. It's been so stressful for me to even think about having my own family
- C. I don't even know who I am yet, & now I'm supposed to know what to do
- D. My girlfriend is pregnant, & I don't think I have what it takes to be a good father
Correct Answer: C
Rationale: The correct answer is C because the young adult expressing uncertainty about their own identity indicates a potential issue with self-awareness and self-esteem, which are foundational for healthy development. This can impact decision-making and overall well-being. Choices A, B, and D focus on external factors (living situation, family stress, and impending fatherhood) that can be addressed once the individual's self-identity is better understood. Prioritizing self-discovery and self-acceptance can lead to more effective coping mechanisms and decision-making skills for handling other stressors.
Nurse is reviewing safety precautions with group of young adults at community health fair. Which recommendations should nurse include specifically for this age group? (Select all that apply.)
- A. Install bath rails & grab bars in bathrooms
- B. Wear helmet while skiing
- C. Install carbon monoxide detector
- D. Secure firearms in safe location
- E. Remove throw rugs from the home
Correct Answer: B,C,D
Rationale: The correct answers are B, C, and D. Young adults are more likely to engage in risky activities like skiing, hence wearing a helmet (B) is crucial for head protection. Carbon monoxide exposure is a concern in any age group, so installing a detector (C) is important. Young adults may have access to firearms, making it vital to secure them in a safe location (D) to prevent accidents. Choices A and E are more relevant for older adults to prevent falls, while F and G are not provided in the question.
Nurse planning diversionary activities for children on an inpatient unit. Which should nurse incorporate as appropriate play activities for toddler? (Select all that apply.)
- A. Building simple models
- B. Working with clay
- C. Filling & emptying containers
- D. Playing with blocks
- E. Looking at books
Correct Answer: C,D,E
Rationale: The correct activities for toddlers should focus on their developmental needs. Filling & emptying containers (C) helps with sensory exploration and fine motor skills. Playing with blocks (D) enhances problem-solving and hand-eye coordination. Looking at books (E) promotes language development and cognitive skills. Building simple models (A) and working with clay (B) may not be suitable for toddlers due to potential choking hazards and fine motor skill requirements.
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.