Nokea
The nurse is reviewing the medical record of a 4-year-old client with failure to thrive. Which of the following risk factors likely contribute to the client's condition? Select all that apply.
- A. Child is the youngest of four children in the home
- B. One parent is incarcerated for spousal abuse
- C. One parent was diagnosed with anorexia nervosa prior to having children
- D. One parent works a full-time job outside the home
- E. Parents are concerned about not having enough money to buy food
Correct Answer: B,C,E
Rationale: FTT risk factors include parental incarceration causing family stress, a history of anorexia nervosa affecting feeding practices, and food insecurity . Being the youngest or a working parent are not direct risks.
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The nurse responds to the call light of a client with chronic obstructive pulmonary disease (COPD) who says, 'I can't breathe.' The client seems to be having difficulty breathing and is nervous and tremulous. Vital signs are stable, oxygen saturation is 92% on 2 L, and there are clear breath sounds bilaterally. Which intervention would be most appropriate at this time?
- A. Administer albuterol nebulizer
- B. Assist the client in identifying the trigger and ways to avoid it
- C. Coach the client through controlled breathing exercises
- D. Continue to monitor oxygen saturation
Correct Answer: C
Rationale: For a COPD client with anxiety-driven dyspnea, stable vitals, and clear lungs, coaching controlled breathing helps reduce anxiety and improve breathing patterns. Albuterol is for bronchospasm, trigger identification is secondary, and monitoring is insufficient alone.
When walking past a client's room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention?
- A. If we work together we can get all of the client care completed.
- B. Since I am late for lunch, would you do this one client's glucose test?
- C. If we client seems confused, we need to watch another closely.
- D. I'll come back and make the bed after I go to the lab.
Correct Answer: B
Rationale: Only the RN and PN can delegate to UAPs. One UAP cannot delegate a task to another UAP. The RN or PN is legally accountable for the nursing care.
What socioeconomic indicators would the nurse identify as risk factors for a 2-month-old infant to develop failure to thrive (FTT)? Select all that apply.
- A. Both caregivers work outside the home
- B. Infant lives only with mother, who is currently unemployed
- C. Infant's primary caregiver has cognitive disabilities
- D. Parents are socially and emotionally isolated
- E. Parents live together but are not married
Correct Answer: B,C,D
Rationale: Risk factors for FTT include unemployment limiting resources, caregiver cognitive disabilities impairing care, and social/emotional isolation reducing support. Working parents and unmarried status are not direct risks.
A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority?
- A. Maintaining proper body alignment
- B. Frequent neurovascular assessments of the affected leg
- C. Inspection of pin sites for evidence of drainage or inflammation
- D. Applying an over-bed trapeze to assist the client with movement in bed
Correct Answer: B
Rationale: The most important activity for the nurse is to assess neurovascular status. Compartment syndrome is a serious complication of fractures. Prompt recognition of this neurovascular problem and early intervention may prevent permanent limb damage.
The nurse notes all of the following. Which should be attended to first?
- A. A blind client is calling out stating that she cannot find the call bell.
- B. There is a water spill on the floor near the bed of an elderly client who ambulates regularly.
- C. A postoperative client is asking for pain medication.
- D. A diabetic client is asking for a glass of water.
Correct Answer: B
Rationale: A water spill near an ambulatory elderly client's bed poses an immediate fall risk, requiring prompt attention to ensure safety. Call bell access, pain, or water requests are less critical.