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The nurse is reinforcing teaching to the parents of a hospitalized 3-month-old about separation anxiety. The nurse notices that the parents still seem concerned about leaving the infant while they work. Which statement by one of the parents indicates that the teaching has been effective?
- A. At this age, my baby will not cry because we are leaving.
- B. I know my baby will feel abandoned when we leave.
- C. My baby is too young to sense my anxiety about leaving.
- D. My baby understands that we will return later in the day.
Correct Answer: C
Rationale: Infants at 3 months (C) do not yet exhibit separation anxiety and cannot sense parental anxiety. Crying (A), feeling abandoned (B), and understanding return (D) occur later in development.
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The nurse can best ensure the safety of a client suffering from dementia who wanders from the room by which action?
- A. Repeatedly remind the client of the time and location
- B. Explain the risks of walking with no purpose
- C. Use protective devices to keep the client in the bed or chair in the room
- D. Attach a wander-guard sensor band to the client's wrist
Correct Answer: D
Rationale: This type of identification band easily tracks the client's movements and ensures safety while the client wanders on the unit. Restriction of activity is inappropriate for any client unless they are potentially harmful to themselves or others.
Because the client has hypothyroidism, the nurse expects which of the following to be present in the client?
- A. Weight loss
- B. Respiratory rate of 30/minute
- C. Temperature of 96.8°F
- D. Scanty menses
Correct Answer: C
Rationale: Hypothyroidism slows metabolism, causing hypothermia (e.g., 96.8°F). Weight gain, not loss, slow respirations, and heavy menses are typical.
A charge nurse suspects that the unlicensed assistive personnel (UAP) is falsifying the documentation of clients' capillary glucose results rather than performing the test. What is the best action by the charge nurse to handle this situation?
- A. Ask a client if the UAP has performed the test
- B. Discuss the importance of task completion and accurate documentation in a staff meeting
- C. Give the UAP a verbal warning not to falsify data
- D. Take a client's capillary glucose personally and compare it to the recorded result
Correct Answer: D
Rationale: Verifying the glucose result personally (D) provides evidence of falsification. Asking a client (A) is unreliable, a staff meeting (B) is too general, and a warning (C) is premature without proof.
The nurse assesses a client for physiological risk factors for falls. The nurse should conclude that the client is not at risk if which of the following is discovered?
- A. history of dizziness
- B. need for wheelchair due to reduced mobility
- C. weakness and fatigue noted when climbing stairs
- D. intact recent and remote memory
Correct Answer: D
Rationale: Intact recent and remote memory indicates that a client is not at risk for falls. Risk for falls can occur in elder clients, and the nurse should assess each client for the possibility of falls and take appropriate actions.
The nurse is reviewing a nutritional plan for a 6-month-old who has recently been started on solid foods. Which of the following recommendations has the highest priority in the plan?
- A. Canned baby food is more expensive than food prepared at home
- B. Finger foods can be introduced before the child has teeth
- C. New foods should be introduced at least 5-7 days apart
- D. Rice cereal can be mixed with cow's milk to increase nutritional intake
Correct Answer: C
Rationale: Introducing new foods 5-7 days apart (C) prevents allergic reactions by identifying triggers, making it the priority. Cost (A), finger foods (B), and cow's milk (D, not recommended before 12 months) are secondary.