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The nurse is caring for a client with a history of eating disorders.
- A. Which client statement indicates a need for further teaching about anorexia nervosa?
- B. I need to gain weight slowly to stay healthy.'
- C. I can stop dieting once I reach my goal weight.'
- D. I should eat balanced meals regularly.'
- E. I need support to change my eating habits.'
Correct Answer: B
Rationale: Stating that dieting can stop at a goal weight suggests a misunderstanding, as anorexia requires ongoing nutritional and psychological management. Slow weight gain, balanced meals, and support are correct.
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The nurse is caring for a client with a history of peripheral artery disease.
- A. Which symptom is expected in a client with peripheral artery disease?
- B. Warm, red skin on the legs.
- C. Intermittent claudication.
- D. Swelling in the ankles.
- E. Numbness in the arms.
Correct Answer: B
Rationale: Intermittent claudication (leg pain with activity, relieved by rest) is a hallmark of peripheral artery disease due to reduced blood flow. Warm skin and swelling suggest venous issues, and arm numbness is unrelated.
The nurse is preparing discharge teaching for the parents of a newborn. Which of the following information should the nurse provide to the parents regarding the accuracy of a PKU (phenylketonuria) Test ?
- A. Breast-fed babies need to be a week old for the Test , and infants on formula can be Test ed in three days.
- B. The Test will need to be repeated at six weeks and at the three-month.pnlcheck-up.
- C. Blood will be drawn at three one-hour intervals; there is no specific preparation.
Correct Answer: A
Rationale: formula or cow's milk contains high phenylalanine levels; Test can be done after three days of formula intake; if mother is breastfeeding, infant will need to return in one week for Test
The nurse is caring for a four-year-old child with a closed head injury. The nurse would be reassured by which of the following observations?
- A. The child is able to state his name when asked who he is.
- B. The child reaches for a stuffed animal brought from home.
- C. The child maintains himself in opisthotonos.
- D. The child withdraws from mildly painful stimuli.
Correct Answer: A
Rationale: Stating his name indicates orientation, a positive sign post-head injury. Options B, C, and D are less reassuring: reaching for a toy is nonspecific, opisthotonos suggests meningeal irritation, and withdrawal may occur in unconscious states.
The nurse is caring for a client with a history of peptic ulcer disease.
- A. Which dietary instruction is most appropriate for a client with peptic ulcer disease?
- B. Avoid spicy foods and caffeine.
- C. Eat large meals three times daily.
- D. Consume high-fat foods to coat the stomach.
- E. Drink alcohol in moderation.
Correct Answer: A
Rationale: Avoiding spicy foods and caffeine reduces gastric irritation in peptic ulcer disease. Small, frequent meals are preferred, high-fat foods delay healing, and alcohol exacerbates ulcers.
An elderly client who has just had a prosthetic hip implant.
The nurse should position the client
- A. with the affected hip internally rotated and flexed.
- B. with the affected hip adducted when turned.
- C. in the supine position with the knees elevated 90°.
- D. side-lying with the affected hip in a position of abduction.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) flexion beyond 60°, adduction and internal rotation should be avoided in the early postoperative period (2) flexion beyond 60°, adduction and internal rotation should be avoided in the early postoperative period (3) flexion beyond 60°, adduction and internal rotation should be avoided in the early postoperative period (4) correct-position of abduction should be maintained