Nokea
The nurse is caring for a client who was recently admitted with a diagnosis of anorexia nervosa. When the nurse enters the room, the client is engaged in rigorous push-ups. Which nursing action should the nurse implement?
- A. Allowing the client to complete the exercise program
- B. Interrupting the client and weigh the client immediately
- C. Interrupting the client and offer to take the client for a walk
- D. Telling the client that he or she is not allowed to exercise rigorously
Correct Answer: C
Rationale: Clients with anorexia nervosa are frequently preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise, as well as place limits on rigorous activities. Allowing the client to complete the exercise program could be harmful. Weighing the client reinforces the altered self-concept that the client experiences and the client's need to control weight. Telling the client that he or she is not allowed to exercise rigorously will increase his or her anxiety.
You may also like to solve these questions
The nurse is developing a care plan for a client experiencing urge urinary incontinence. Which interventions would be helpful for this type of incontinence? Select all that apply.
- A. Surgery
- B. Bladder retraining
- C. Scheduled toileting
- D. Dietary modifications
- E. Pelvic muscle exercises
- F. Intermittent catheterization
Correct Answer: B,C,D,E
Rationale: Urge incontinence is the involuntary passage of urine after a strong sense of the urgency to void. It is characterized by urinary urgency, often with frequency (more often than every 2 hours); bladder spasm or contraction; and voiding in either small amounts (less than 100 mL) or large amounts (greater than 500 mL). It can be caused by decreased bladder capacity, irritation of the bladder stretch receptors, infection, and alcohol or caffeine ingestion. Interventions to assist the client with urge incontinence include bladder retraining, scheduled toileting, dietary modifications such as eliminating alcohol and caffeine intake, and pelvic muscle exercises to strengthen the muscles. Surgery and urinary catheterization are invasive measures and will not assist in the treatment of urge incontinence.
A client admitted to the nursing unit with a closed head injury 6 hours ago has begun to vomit, and reports being dizzy and having a headache. Based on these data, which is the most important nursing action?
- A. Administering a prescribed antiemetic
- B. Notifying the primary health care provider of the client's condition
- C. Having the client rate the headache pain on a scale of 1 to 10
- D. Reminding the client to use the call bell when needing help to the bathroom
Correct Answer: B
Rationale: The client with a closed head injury is at risk of developing increased intracranial pressure (ICP). Increased ICP is evidenced by signs and symptoms such as headache, dizziness, confusion, weakness, and vomiting. Because of the implications of the client's manifestations, the most important nursing action is to notify the primary health care provider. Although the other nursing actions are not inappropriate, none of them address the critical issue of the potential of the client developing ICP.
Which nursing question would elicit the most thorough assessment data regarding the client's recent sleeping patterns?
- A. Are you sleeping well at home?
- B. Did you get much sleep last night?
- C. May we talk about how you've been sleeping?
- D. Do you think you get enough sleep on a nightly basis?
Correct Answer: C
Rationale: Option 3 is a question and provides the client the opportunity to express thoughts and feelings. The remaining options could lead to a one-word answer that would not provide thorough assessment data. Additionally, one night of sleep may not tell the nurse how the pattern has been over time.
The nurse is caring for a client diagnosed with active tuberculosis who is prescribed rifampin therapy. The nurse instructs the client to expect which side effect of this medication?
- A. Green urine
- B. Yellow sclera
- C. Orange secretions
- D. Clay-colored stools
Correct Answer: C
Rationale: Rifampin is an antituberculosis medication. Secretions will become orange in color as a result of the rifampin. The client should be instructed that this side effect will likely occur.
Which interventions should the emergency department nurse prepare for in the care of a child with croup and epiglottitis? Select all that apply.
- A. Obtaining a chest x-ray
- B. Obtaining a throat culture
- C. Monitoring pulse oximetry
- D. Maintaining a patent airway
- E. Providing humidified oxygen
- F. Administering antipyretics and antibiotics
Correct Answer: A,C,D,E,F
Rationale: Epiglottitis is an acute inflammation and swelling of the epiglottis and surrounding tissue. It is a life-threatening, rapidly progressive condition that may cause complete airway obstruction within a few hours of onset. The most reliable diagnostic sign is an edematous, cherry-red epiglottis. Some interventions include obtaining a chest x-ray film, monitoring pulse oximetry, maintaining a patent airway, providing humidified oxygen, and administering antipyretics and antibiotics. The child may also require intubation and mechanical ventilation. The primary concern in a child with epiglottitis is the development of complete airway obstruction. Therefore, the child's throat is not examined or cultured because any stimulation with a tongue depressor or culture swab could trigger complete airway obstruction.