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The nurse is assisting in developing the plan of care for a client diagnosed with anorexia nervosa who is being admitted after unsuccessful outpatient treatment. The nurse understands that which client outcome is the priority?
- A. Acknowledges poor interpersonal skills
- B. Identifies new coping mechanisms
- C. Increases caloric intake to gain weight
- D. Verbalizes sources of conflict and anger
Correct Answer: C
Rationale: In anorexia nervosa, severe malnutrition poses immediate health risks, making increased caloric intake and weight gain the priority to stabilize physical health. Addressing interpersonal skills, coping mechanisms, or emotional conflicts is secondary until nutritional status improves.
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The nurse is observing a staff member perform open suctioning for a client who has a tracheostomy tube. The nurse should intervene if the staff member is observed
- A. flushing the suction catheter with 0.9% sodium chloride after each suction pass
- B. placing the client in the semi-Fowler position prior to suctioning
- C. applying intermittent suction while inserting the suction catheter
Correct Answer: C
Rationale: Applying suction while inserting the catheter can cause tracheal mucosa damage and hypoxia. Flushing the catheter with saline maintains patency, and semi-Fowler position aids breathing and reduces aspiration risk during suctioning.
The nurse is giving instructions to a group of women about breast self-examination. Which statement indicates that the client needs more instruction about the procedure?
- A. I will perform the exam every month after my period.'
- B. I should do the exam both standing and lying down.'
- C. Some ridges are normal in my breast.'
- D. I will do the breast self-exam every month until menopause.'
Correct Answer: D
Rationale: Breast self-exams should continue lifelong, not stop at menopause, as breast cancer risk persists. Other statements reflect correct technique.
A client is waiting to have an intravenous pyelogram (IVP). The most important information to be obtained by the nurse prior to the procedure is
- A. time of the client's last meal
- B. client's allergy history
- C. assessment of the peripheral pulses
- D. results of the blood coagulation studies
Correct Answer: B
Rationale: Intravenous Pyelogram is a dye study that uses an iodine-based contrast. Therefore, the study is contraindicated in clients with allergy to iodine.
A health care provider is screaming at the nurse in the hallway. 'Why didn't you get that surgery scheduled sooner?' What is the best response by the nurse?
- A. I am so sorry; I will get this fixed and schedule the surgery immediately
- B. I am uncomfortable with your tone, please excuse me while I locate my supervisor
- C. I delegated this task to the unlicensed assistive personnel: please follow up with them.
- D. I think you are overreacting, you should have specified the day and time
Correct Answer: B
Rationale: Responding calmly and redirecting to a supervisor de-escalates the situation professionally while addressing the inappropriate tone. Accusing the provider of overreacting is confrontational and unprofessional.
The nurse has been assigned a client who is thought to be suicidal. All of the following are in the client's room. Which is safe to leave in the room?
- A. Paper cup
- B. Leather belt
- C. Razor
- D. Pillow
Correct Answer: A
Rationale: A paper cup poses no suicide risk. Belts, razors, and pillows (potential suffocation) are unsafe in a suicidal client's room.