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
What advice should be provided by the practical nurse to the mother of a school-age child with acute diarrhea and mild dehydration who is occasionally vomiting despite being given an oral rehydration solution (ORS)?
- A. Continue to give ORS frequently in small amounts.
- B. Alternate between ORS and carbonated beverages.
- C. Take the child to the hospital for intravenous fluids.
- D. Place the child NPO for the next eight to nine hours.
Correct Answer: A
Rationale: The practical nurse should advise the mother to continue providing the oral rehydration solution (ORS) frequently in small amounts. It is essential to continue ORS administration to prevent dehydration, even if the child is occasionally vomiting. Small, frequent amounts of ORS help maintain hydration levels in children with acute diarrhea and mild dehydration.
During a routine assessment of a 3-year-old at a community health center, the healthcare professional should be alert for signs of autism spectrum disorder. Which behavior by the child should prompt further evaluation for a possible autistic spectrum disorder?
- A. Engages in odd repetitive behaviors
- B. Shows indifference to verbal stimulation
- C. Strokes the hair of a hand-held doll
- D. Has a history of temper tantrums
Correct Answer: A
Rationale: Engaging in odd repetitive behaviors is a hallmark sign of autism spectrum disorder in children. These behaviors can include repetitive movements, insistence on sameness, or specific routines. Recognizing and addressing these behaviors early can help in providing appropriate interventions and support for the child.
A 16-year-old female student with a history of asthma controlled with both an oral antihistamine and an albuterol (Proventil) metered-dose inhaler (MDI) comes to the school nurse. The student complains that she cannot sleep at night, feels shaky, and her heart feels like it is 'beating a mile a minute.' Which information is most important for the nurse to obtain?
- A. When she last took the antihistamine.
- B. When her last asthma attack occurred.
- C. Duration of most asthma attacks.
- D. How often the MDI is used daily.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a follow-up clinical visit, a mother tells the nurse that her 5-month-old son, who had surgical correction for tetralogy of Fallot, has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held, and his growth is in the expected range. Which intervention should the nurse implement?
- A. Stimulate the infant to cry to produce cyanosis
- B. Auscultate the heart and lungs while the infant is held
- C. Evaluate the infant for failure to thrive
- D. Obtain a 12-lead electrocardiogram
Correct Answer: B
Rationale: Auscultating the heart and lungs while the infant is held can provide important diagnostic information in assessing the cardiac and respiratory status of the infant who had surgical correction for tetralogy of Fallot. This intervention can help the nurse identify any abnormal heart or lung sounds, which may indicate complications or issues that need further evaluation or intervention.
A 6 year old who has asthma is demonstrating a prolonged expiratory phase and wheezing and has a 35% of personal best peak expiratory flow rate (PEFR). Based on these findings, what actions should the nurse take first?
- A. Administer a prescribed bronchodilator.
- B. Encourage the child to cough and deep breath.
- C. Report findings to the health care provider.
- D. Determine what triggers precipitated this attack.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.