Nokea
The nurse is assessing the integumentary system of the client diagnosed with anorexia nervosa. Which finding supports the diagnosis?
- A. Preoccupation with calories.
- B. Thick body hair.
- C. Sore tongue.
- D. Dry, brittle hair.
Correct Answer: D
Rationale: Dry, brittle hair is a common integumentary finding in anorexia nervosa due to malnutrition. Preoccupation is psychological, thick hair is unrelated, and sore tongue is less specific.
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The nurse is teaching the client diagnosed with colon cancer who is scheduled for a colostomy. Which behavior indicates the nurse is utilizing adult learning principles?
- A. The nurse repeats the information as indicated by the client's questions.
- B. The nurse teaches in one session all the information the client needs.
- C. The nurse uses a video so the client can hear the medical terms.
- D. The nurse waits until the client asks questions about the surgery.
Correct Answer: A
Rationale: Repeating information based on client questions respects adult learning principles by addressing the learner’s needs and reinforcing understanding. One-session teaching, videos, or waiting for questions are less interactive.
The dietitian and the nurse in a long-term care facility are planning the menu for the day. Which foods should be recommended for the immobile clients for whom swallowing is not an issue?
- A. Cheeseburger and milk shake.
- B. Canned peaches and a sandwich on whole-wheat bread.
- C. Mashed potatoes and mechanically ground red meat.
- D. Biscuits and gravy with bacon.
Correct Answer: C
Rationale: Mashed potatoes and ground meat are soft, low-fiber, and digestible, suitable for immobile clients to prevent constipation. Burgers, whole-wheat, and fatty foods are harder to digest.
Which nursing problem is priority for the 76-year-old client diagnosed with gastroenteritis from staphylococcal food poisoning?
- A. Fluid volume deficit.
- B. Nausea.
- C. Risk for aspiration.
- D. Impaired urinary elimination.
Correct Answer: A
Rationale: Fluid volume deficit is the priority in elderly patients with gastroenteritis, as dehydration from vomiting and diarrhea poses significant risks. Nausea, aspiration, and urinary issues are secondary.
The clinic nurse is talking on the phone to a client who has diarrhea. Which intervention should the nurse discuss with the client?
- A. Tell the client to measure the amount of stool.
- B. Recommend the client come to the clinic immediately.
- C. Explain the client should follow the BRAT diet.
- D. Discuss taking an over-the-counter histamine-2 blocker.
Correct Answer: C
Rationale: The BRAT diet (bananas, rice, applesauce, toast) is bland and helps manage diarrhea. Measuring stool is impractical, immediate clinic visits depend on severity, and H2 blockers are irrelevant.
The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement indicates the discharge teaching is effective?
- A. I will take my lipid-lowering medicine at the same time each night.
- B. I may experience some discomfort when I eat a high-fat meal.
- C. I need someone to stay with me for about a week after surgery.
- D. I should not splint my incision when I deep breathe and cough.
Correct Answer: B
Rationale: High-fat meals may cause discomfort post-cholecystectomy due to altered bile flow, indicating understanding of dietary adjustments. Lipid-lowering drugs, prolonged supervision, and avoiding splinting are incorrect.