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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.
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The practical nurse is reinforcing information about Lyme disease prevention with a client who is preparing for a camping trip with family. Which statement by the client informs the nurse that the client understands the instruction?
- A. I'll make sure my son wears dark clothing on his hike.
- B. I'll get a prescription for amoxicillin to take with us.
- C. We should all get the Lyme disease vaccine before our trip.
- D. We will wear long pants and long-sleeved shirts in the woods.
Correct Answer: D
Rationale: The correct answer is D. Wearing long pants and long-sleeved shirts is an effective preventive measure against tick bites, which reduces the risk of contracting Lyme disease. This attire helps to minimize skin exposure to ticks, thereby decreasing the chances of a tick attaching and transmitting the disease-causing bacteria.
A 2-year-old child with respiratory syncytial virus (RSV) is being treated in the hospital. What should the healthcare provider monitor for in this child?
- A. Increased urine output.
- B. Decreased respiratory rate.
- C. Labored breathing.
- D. Improved appetite.
Correct Answer: C
Rationale: Labored breathing is a critical sign of worsening respiratory distress in children with RSV. It indicates that the child's condition may be deteriorating, requiring prompt intervention to ensure adequate oxygenation and prevent respiratory failure. Monitoring for labored breathing allows healthcare providers to promptly assess and manage the child's respiratory status, potentially preventing further complications associated with RSV infection.
What information should the nurse provide the parents of a 3-year-old boy with Duchenne muscular dystrophy (DMD) who are concerned about having more children?
- A. This is an inherited X-linked recessive disorder, which primarily affects male children in the family.
- B. The male infant had a viral infection that went unnoticed and untreated, leading to muscle damage.
- C. The mother's lack of the protein dystrophin can impact the XXXX muscle groups in males.
- D. Birth trauma during a breech vaginal birth can damage the spinal cord, resulting in muscle weakness.
Correct Answer: A
Rationale: The correct answer is A. Duchenne muscular dystrophy is an inherited X-linked recessive disorder that primarily affects male children in the family. Since it is X-linked, sons inherit the mutation from their mothers who are carriers of the abnormal gene. Therefore, the nurse should explain to the parents that any future sons they have would have a 50% chance of inheriting the mutation and having DMD, while daughters would have a 50% chance of being carriers like the mother.
When developing a behavior modification program for an extremely aggressive 10-year-old boy, what should the nurse do first?
- A. Identify what activities, foods, and toys the child enjoys
- B. Assess the child's previous reactions to punishment
- C. Offer the child positive feedback
- D. Involve other children on the unit in describing the token system
Correct Answer: A
Rationale: The first step in developing a behavior modification program for an extremely aggressive 10-year-old boy is to identify what activities, foods, and toys the child enjoys. Understanding the child's motivations is crucial in creating an effective behavior modification plan tailored to his interests and preferences, which can help in positively reinforcing desired behaviors.
The practical nurse is caring for a child who was admitted for treatment of seizures. Which intervention should the nurse implement to help prevent injury from a seizure?
- A. Have a padded tongue depressor at the bedside.
- B. Keep the side rails padded and in an upright position.
- C. Place a padded helmet on the child's head.
- D. Restrain the child during the seizure activity.
Correct Answer: B
Rationale: The correct intervention to help prevent injury during a seizure is to keep the side rails padded and in an upright position. This measure helps to ensure the child's safety by preventing falls or accidental injuries. Using a padded tongue depressor or restraining the child can potentially cause harm and are not recommended. Placing a padded helmet is not a standard intervention for seizure safety in this scenario.