Nokea
The nurse writes a problem 'low self-esteem' for a 16-year-old client diagnosed with anorexia. Which client goal should be included in the plan of care?
- A. The client will spend one (1) hour a day with the parents.
- B. The client eats 50% of the meals provided.
- C. Dietary will provide high-protein milk shakes (tid).
- D. The client will verbalize one positive attribute.
Correct Answer: D
Rationale: Verbalizing a positive attribute directly addresses low self-esteem by fostering positive self-perception. Time with parents, eating, and milk shakes are unrelated or nutritional.
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The nurse is caring for the client diagnosed with cirrhosis. After completing discharge education, the nurse recognizes the need for further teaching when the client makes which statement?
- A. “My cirrhosis was caused from too much alcohol; I plan to stop drinking.”
- B. “I need to rest more; I plan on only going to work on a part-time basis.”
- C. “Propranolol has been ordered to decrease my blood pressure.”
- D. “Furosemide will help to reduce the amount of abdominal fluid.”
Correct Answer: C
Rationale: A. Alcohol intake is a major cause of cirrhosis and must be eliminated from the client’s diet. B. Rest may enable the liver to restore itself and should be encouraged. C. Although propranolol (Inderal) does decrease BP, it is not ordered for this purpose in treating cirrhosis. Prophylactic treatment with a nonselective beta blocker like propranolol has been shown to reduce the risk of bleeding from esophageal varices and to reduce bleeding-related deaths. D. Furosemide (Lasix) is used in combination with potassium-sparing diuretics to decrease ascites.
The nurse is preparing to administer the initial dose of an aminoglycoside antibiotic to the client diagnosed with acute diverticulitis. Which intervention should the nurse implement?
- A. Obtain a serum trough level.
- B. Ask about drug allergies.
- C. Monitor the peak level.
- D. Assess the vital signs.
Correct Answer: B
Rationale: Checking for drug allergies before administering an aminoglycoside prevents allergic reactions, a critical safety step. Trough and peak levels are monitored later, and vital signs are routine but not specific to the initial dose.
The nurse is irrigating the client's colostomy when the client complains of cramping. What is the most appropriate initial action by the nurse?
- A. Increase the flow of solution
- B. Ask the client to turn to the other side
- C. Pinch the tubing to interrupt the flow of the solution
- D. Remove the tube from the colostomy
Correct Answer: C
Rationale: Pinching the tubing stops the flow, relieving cramping caused by rapid fluid instillation during colostomy irrigation.
The male client had abdominal surgery and the nurse suspects the client has peritonitis. Which assessment data support the diagnosis of peritonitis?
- A. Absent bowel sounds and potassium level of 3.9 mEq/L.
- B. Abdominal cramping and hemoglobin of 14 g/dL.
- C. Profuse diarrhea and stool specimen shows Campylobacter.
- D. Hard, rigid abdomen and white blood cell count 22,000/mm3.
Correct Answer: D
Rationale: A hard, rigid abdomen and elevated WBC count (22,000/mm3) indicate peritonitis due to peritoneal inflammation and infection. Absent bowel sounds are nonspecific, cramping with normal hemoglobin is less indicative, and diarrhea with Campylobacter suggests gastroenteritis.
The client is diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms?
- A. Instruct the client to avoid drinking fluids with meals.
- B. Explain the need to decrease intake of flatus-forming foods.
- C. Teach the client how to perform gentle perianal care.
- D. Encourage the client to attend a support group meeting.
Correct Answer: B
Rationale: Decreasing flatus-forming foods (e.g., beans, broccoli) reduces bloating and discomfort in IBS. Avoiding fluids with meals is not standard, perianal care is secondary, and support groups are psychosocial.