Nokea
The nurse is caring for a client with anorexia nervosa. After experiencing a weight gain of 2 lb (0.9 kg), the client states, 'See what you have done to me? I am fatter and uglier than ever.' Which of the following actions would be most appropriate for the nurse to take?
- A. Acknowledge the client's distress and explore the client's underlying feelings.
- B. Remind the client that gaining weight is a criterion for discharge home.
- C. Encourage the client to write about the client's feelings in a journal
- D. Recommend the client receive cognitive behavioral therapy.
Correct Answer: A
Rationale: Acknowledging distress and exploring feelings builds trust and addresses body image issues. Discharge criteria , journaling , or therapy are less immediate.
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A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply.
- A. Ask a family member about the client's preferences for room arrangement
- B. Offer the client an elbow to hold, and walk a half-step ahead for guidance
- C. Say 'goodbye' when leaving the room to help orient the client
- D. Speak slowly and slightly louder so the client can understand
- E. Use a clock-face pattern to explain food arrangement on the client's meal tray
Correct Answer: B,C,E
Rationale: Guiding with an elbow , saying goodbye , and clock-face food arrangement promote safety and orientation. Family input is secondary, and louder/slower speech is unnecessary unless hearing-impaired.
A client with chronic bronchitis tells the home health nurse of being exhausted all day due to coughing all night and being unable to sleep. The client can feel thick mucus in the chest and throat. Which teaching can the nurse reinforce to help the client mobilize secretions and improve sleep? Select all that apply.
- A. Increase fluids to at least 8 glasses (2-3 L) of water a day
- B. Sleep with a cool mist humidifier
- C. Take prescribed guaifenesin cough medicine before bedtime
- D. Use abdominal breathing and the huff cough technique at bedtime
- E. Use pursed lip breathing during the night
Correct Answer: A,B,C,D
Rationale: Fluids , humidifiers , guaifenesin , and huff coughing thin and mobilize secretions. Pursed lip breathing aids exhalation, not secretion clearance.
A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering?
- A. 0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours
- B. IV bolus of 1000 mL 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy
- C. IV bolus of 1000 mL 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dL (36.1 mmol/L)
- D. IV mannitol 25% solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure
Correct Answer: C
Rationale: 0.45% saline is appropriate for gastroenteritis to replace fluids. 0.9% saline bolus treats anaphylactic shock. Mannitol reduces intracranial pressure. A 1000 mL bolus for DKA is excessive; smaller boluses (e.g., 250-500 mL) are safer to avoid fluid overload.
The clinic nurse is interviewing the parents of a 6-month-old client about the infant's diet. Which statement by the parents is most concerning?
- A. Because apples are healthy, we make apple pie and feed small, soft bites to our baby.
- B. If our baby refuses to finish foods, we continue to offer small bites, so food isn't wasted.
- C. Infant oatmeal sweetened with fresh honey is our baby's favorite breakfast.
- D. We found that the food in TV dinners can be easily pureed and is convenient.
Correct Answer: C
Rationale: Honey poses a botulism risk in infants under 1 year, making it the most concerning. Apple pie and TV dinners are inappropriate but less dangerous, and offering bites is not harmful.
A nurse at outpatient clinic is returning phone calls that have been made to the clinic. Which of the following calls should have the highest priority for medical intervention?
- A. A home health patient reports, 'I am starting to have breakdown of my heels.'
- B. A patient that received an upper extremity cast yesterday reports, 'I can't feel my fingers in my right hand today.'
- C. A young female reports, 'I think I sprained my ankle about 2 weeks ago.'
- D. A middle-aged patient reports, 'My knee is still hurting from the TKR.'
Correct Answer: B
Rationale: The patient experiencing neurovascular changes should have the highest priority. Pain following a TKR is normal, and breakdown over the heels is a gradual process. Moreover, a subacute ankle sprain is almost never a medical emergency.