Nokea
The nurse is caring for a 15-year-old adolescent who is admitted with a diagnosis of bulimia nervosa. The adolescent's vital signs are stable, but the nurse notes that the client has dry skin and appears thin. What is the nurse's priority action?
- A. Initiate a structured eating plan for the client
- B. Establish a therapeutic relationship with the client
- C. Monitor the client's electrolyte levels
- D. Provide education on healthy eating habits
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
You may also like to solve these questions
A 5-year-old child with leukemia is receiving chemotherapy. The nurse notes that the child's white blood cell count is low. What is the nurse's priority intervention?
- A. Administer antibiotics as prescribed
- B. Place the child in protective isolation
- C. Encourage the child to eat a balanced diet
- D. Teach the parents about infection prevention
Correct Answer: B
Rationale: The priority intervention for a 5-year-old child with leukemia receiving chemotherapy and having a low white blood cell count is to place the child in protective isolation. This intervention helps reduce the risk of infection, which is crucial in this immunocompromised state. Protective isolation aims to limit the child's exposure to pathogens and promote their safety during a period of increased vulnerability to infections.
A 2-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?
- A. Determine the pulse deficit.
- B. Administer the scheduled dose.
- C. Calculate the safe dose range.
- D. Review the serum digoxin level.
Correct Answer: B
Rationale: Administering the scheduled dose is appropriate in this scenario since the heart rate of 128 bpm is within an acceptable range for a 2-year-old child with heart failure. Monitoring for signs of digoxin toxicity is important; however, the immediate action required is to administer the scheduled dose as prescribed based on the heart rate assessment.
The healthcare provider is assessing an infant with diarrhea and lethargy. Which finding should the provider identify that is consistent with early dehydration?
- A. Tachycardia
- B. Bradycardia
- C. Dry mucous membranes
- D. Decreased skin turgor
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
An 8-year-old male client with nephrotic syndrome is receiving salt-poor human albumin IV. Which findings indicate to the nurse that the child is manifesting a therapeutic response?
- A. Decreased urinary output
- B. Decreased periorbital edema
- C. Increased periods of rest
- D. Weight gain of 0.5 kg/day
Correct Answer: B
Rationale: In nephrotic syndrome treatment, decreased periorbital edema is a positive therapeutic response as it indicates a reduction in fluid retention. Periorbital edema is a common symptom of nephrotic syndrome due to fluid accumulation, so a decrease in this swelling signifies an improvement in the condition.
The nurse is caring for a 14-year-old adolescent who was admitted to the hospital after a suicide attempt. The adolescent's mood appears stable, and the healthcare provider has recommended discharge. What is the nurse's priority action?
- A. Ensure that a safety plan is in place before discharge
- B. Provide education about medication adherence
- C. Encourage the adolescent to participate in group therapy
- D. Schedule a follow-up appointment with a mental health professional
Correct Answer: A
Rationale: The priority action for the nurse is to ensure that a safety plan is in place before discharge. A safety plan is essential to assist the adolescent in managing future crises and decreasing the likelihood of another suicide attempt. It provides guidance on coping strategies and resources to help the adolescent stay safe in times of distress.