Nokea
The nurse advises the parents of a child taking methylphenidate hydrochloride (Ritalin) that, to avoid potentiating the drug's effects, it is best if their child refrains from consuming which food?
- A. Citrus foods
- B. Cola beverages
- C. Processed meats
- D. Saturated fats
Correct Answer: B
Rationale: Caffeine in cola can enhance Ritalin's stimulant effects.
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Which assessment findings are most characteristic of a 10-month-old infant with the diagnosis of failure to thrive?
- A. The infant cries vigorously when handled.
- B. The infant has a delay in developmental milestones.
- C. The infant appears pale and lethargic.
- D. The infant's sucking and grasp reflexes
- E. The infant has delayed understanding of speech.
Correct Answer: B,C,E
Rationale: Delayed milestones, pallor, lethargy, and speech delays are hallmark signs of failure to thrive.
When performing a brief check of the client's mental status, which question is most appropriate for assessing the client's orientation?
- A. What is today's date?
- B. How did you get here?
- C. Where were you born?
- D. Who is currently the U.S. president?
Correct Answer: A
Rationale: Asking the date assesses orientation to time, a key component.
Which nursing action best conveys an interest in this client and her situation?
- A. Making frequent eye contact with her
- B. Reviewing birth control clinic literature
- C. Writing down information the client provides
- D. Avoiding long pauses between questions
Correct Answer: C
Rationale: Writing down information shows attentiveness and validates the client's concerns.
Which nursing action is most appropriate at this time?
- A. Postpone weighing the client until later.
- B. Confront the client about the water intake.
- C. Say nothing and weigh the client as usual.
- D. Subtract 2 lb (0.9 kg) from the client's weight.
Correct Answer: A
Rationale: Postponing weighing ensures accuracy and addresses manipulative behavior.
On the basis of the nurse's knowledge of autistic behavior, which nursing diagnosis is most likely to be a priority in the team conference?
- A. Ineffective health maintenance
- B. Chronic low self-esteem
- C. Risk for activity intolerance
- D. Risk for self-directed violence
Correct Answer: D
Rationale: Self-directed violence is a priority due to potential self-injurious behaviors.