Nokea
The nurse is caring for an adolescent with a 5-year history of bulimia. A common clinical finding in the client with bulimia is:
- A. Extreme weight loss
- B. Dental caries
- C. Hair loss
- D. Decreased temperature
Correct Answer: B
Rationale: Dental caries are common in bulimia due to frequent vomiting, which exposes teeth to stomach acid, causing enamel erosion.
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The nurse recognizes that if eaten by a client, which food can alter results when stool is checked for occult blood?
- A. potatoes
- B. dairy products
- C. raw fruits
- D. beef
Correct Answer: D
Rationale: Beef contains heme, which can cause a false-positive result in a fecal occult blood test. Other foods listed do not typically interfere.
Which of the following medication orders requires clarification before the nurse can administer the order?
- A. epinephrine (EpiPen) 0.25 mg IM STAT
- B. heparin 30 units/kg/hr IV infusion for 24 hours
- C. ampicillin (Omnipen) 500 mg PO bid
- D. lorazepam (Ativan) 1.0 mg PO prn
Correct Answer: B
Rationale: Heparin dosing (30 units/kg/hr) is unusually low for anticoagulation (typically 10-20 units/kg/hr). This requires clarification to ensure safety.
The nurse is caring for clients on a respiratory unit. Upon receiving the following client reports, which client should be seen first?
- A. Client with emphysema expecting discharge
- B. Bronchitis client receiving IV antibiotics
- C. Bronchitis client with edema and neck vein distention
- D. COPD client with PO2 of 85
Correct Answer: C
Rationale: Edema and neck vein distention in a bronchitis client suggest heart failure, a critical condition requiring immediate assessment. The other clients are stable or less urgent.
The nurse is conducting a physical examination of a client's abdomen. Place the examination techniques listed below (Roman numerals) in the correct sequence, from first to last.
- A. Percussion
- B. Palpation
- C. Inspection
- D. Auscultation
Correct Answer: C,D,A,B
Rationale: Abdominal exam sequence: Inspection (III) first, then auscultation (IV) before percussion (I) and palpation (II) to avoid altering bowel sounds.
The nurse is teaching a client with a new diagnosis of epilepsy about self-care. Which of the following instructions should the nurse include?
- A. Avoid swimming or bathing alone.
- B. Take medications only when a seizure occurs.
- C. Drive a car as long as you feel alert.
- D. Consume alcohol in moderation to reduce stress.
Correct Answer: A
Rationale: avoiding swimming or bathing alone reduces the risk of injury during a seizure