The mother is concerned that her 6-year-old child is eating...

The mother is concerned that her 6-year-old child is eating dirt every day. The nurse is most concerned about which of the following?

A. The child may not be getting enough to eat.
B. The child may have lead poisoning.
C. This is normal childhood behavior.
D. The child may have iron deficiency anemia.

Correct Answer: B

Rationale: Pica, such as eating dirt, raises concern for lead poisoning, especially in children, as contaminated soil may contain lead, posing neurological risks.

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The nurse is providing care to a 9-year-old client who is awaiting surgery. Which intervention is developmentally appropriate for this client's plan of care?

A. Discuss the procedure with the client using simple diagrams with correct anatomical terminology
B. Explore the client's perception of how the surgery will positively affect their future
C. Focus primarily on the client's feelings and concerns regarding surgical scar appearance
D. Provide initial education about the procedure to the client immediately before it is performed

Correct Answer: A

Rationale: Using simple diagrams with correct terminology (A) is age-appropriate for a 9-year-old, aiding understanding. Future benefits (B) are abstract, scar concerns (C) are secondary, and last-minute education (D) increases anxiety.

The nurse is caring for a client with bulimia nervosa. It would be a priority for the nurse to

A. place limits on the time allowed for client meals
B. check on the client at irregular intervals during the overnight hours
C. monitor the client for 1 to 2 hours after each meal
D. discuss complications associated with bulimia nervosa with the client

Correct Answer: C

Rationale: Monitoring for 1-2 hours after meals (C) prevents purging, a priority in bulimia management. Time limits (A) may increase anxiety, overnight checks (B) are less relevant, and discussing complications (D) is educational but not immediate.

When writing in the client's chart, the nurse makes an error in documentation. The nurse should:

A. Attempt to erase the error.
B. Blacken the entry with a felt tipped pen.
C. Remove the sheet, rewrite each entry, and initial.
D. Draw a single line through the entry and initial.

Correct Answer: D

Rationale: Drawing a single line through the error and initialing maintains transparency and legality. Erasing, blackening, or rewriting the sheet is improper.

The nurse is caring for a client who has a hip fracture and is placed in Buck traction. Which of the following actions should the nurse take? Select all that apply.

A. Place the client on the affected side.
B. Monitor the client for skin breakdown.
C. Perform frequent neurovascular checks.
D. Keep the affected extremity in a neutral position.
E. Ensure that the client receives adequate pain relief.

Correct Answer: B,C,D,E

Rationale: Monitoring for skin breakdown (B), neurovascular checks (C), neutral positioning (D), and pain relief (E) are essential for Buck traction. Placing the client on the affected side (A) is incorrect as it may disrupt traction.

The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate? Select all that apply.

A. Apply a water-based lubricant to the enema tube before insertion
B. Assist the client into left lateral position with right knee flexed
C. Encourage the client to retain the enema for as long as possible
D. Keep the enema solution refrigerated until ready to administer
E. Stop the infusion briefly if the client reports abdominal cramping

Correct Answer: A,B,C,E

Rationale: Lubricating the tube (A), left lateral positioning (B), retaining the enema (C), and pausing for cramping (E) are correct for safe administration. Refrigerating the solution (D) is incorrect; it should be at body temperature.