Nokea
The nurse is caring for a client diagnosed with bulimia nervosa. Which nursing intervention should the nurse implement after the client's evening meal?
- A. Praise the client for eating all the food on the tray.
- B. Stay with the client for 45 minutes to an hour.
- C. Allow the client to work out on the treadmill.
- D. Place the client on bedrest until morning.
Correct Answer: B
Rationale: Staying with the client prevents purging, a key behavior in bulimia, post-meal. Praising eating, exercise, or bedrest does not address purging.
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Which task should the nurse delegate to the unlicensed assistive personnel (UAP) to improve the desire to eat in a 14-year-old client diagnosed with anorexia?
- A. Administer an antiemetic 30 minutes before the meal.
- B. Provide mouth care with lemon-glycerin swabs prior to the meal.
- C. Create a social atmosphere by interacting with the client.
- D. Encourage the client's parents to sit with the client during meals.
Correct Answer: D
Rationale: Encouraging parents to sit with the client is within the UAP’s scope and promotes a supportive eating environment. Administering medication, mouth care, and creating a social atmosphere require RN skills or specific training.
The nurse is caring for the client with acute diverticulitis. Which finding should most prompt the nurse to consider that the client has developed an intestinal perforation?
- A. White blood cells (WBCs) elevated
- B. Temperature of 101°F (38.3°C)
- C. Bowel sounds are absent
- D. Reports intense abdominal pain
Correct Answer: C
Rationale: A. Elevated WBCs are a symptom of acute diverticulitis. B. Increased temperature is a symptom of acute diverticulitis. C. Clients with intestinal perforation develop paralytic ileus. Bowel sounds would be absent. D. Abdominal pain is a symptom of acute diverticulitis that may worsen with intestinal perforation, but the most significant finding would be absent bowel sounds.
The client has diarrhea that has been cultured positive for Clostridium difficile (C. diff). In order to prevent the spread of infection, the nurse should perform which intervention?
- A. Wear an isolation gown, gloves, and mask when providing care.
- B. Perform vigorous hand hygiene using only soap and water.
- C. Place the client in a private room with negative pressure airflow.
- D. Instruct visitors to use the alcohol-based hand wash for self-protection.
Correct Answer: B
Rationale: A. The nurse does not need to wear a mask when caring for the client; the bacterium is transmitted through direct contact. B. Hand washing with soap and water is performed instead of using alcohol—based hand cleaners; alcohol-based cleaners lack sporicidal activity. Even vigorous scrubbing with soap and water does not kill all of the spores. C. The client should be in a private room but does not need a negative pressure room. Negative pressure rooms are used with airborne diseases. D. The spores of C. diff can survive on inanimate objects such as tables and bedrails. For self-protection, visitors should be instructed to wash vigorously with soap and water and not to use the alcohol-based hand wash.
The nurse identifies the client problem 'excess fluid volume' for the client in liver failure. Which short-term goal would be most appropriate for this problem?
- A. The client will not gain more than two (2) kg a day.
- B. The client will have no increase in abdominal girth.
- C. The client's vital signs will remain within normal limits.
- D. The client will receive a low-sodium diet.
Correct Answer: B
Rationale: No increase in abdominal girth indicates stable ascites, directly addressing excess fluid volume. Weight gain limits, vital signs, and diet are related but less specific.
The nurse has received the a.m. shift report. Which client should the nurse assess first?
- A. The 44-year-old client diagnosed with peptic ulcer disease who is complaining of acute epigastric pain.
- B. The 74-year-old client diagnosed with acute gastroenteritis who has had four (4) diarrhea stools during the night.
- C. The 65-year-old client diagnosed with IBD who has tented skin turgor and dry mucous membranes.
- D. The 15-year-old client diagnosed with food poisoning who has vomited several times during the night shift.
Correct Answer: C
Rationale: Tented skin turgor and dry mucous membranes in an elderly IBD patient indicate severe dehydration, a life-threatening condition requiring immediate assessment. Other clients have concerning but less urgent symptoms.