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The parents of a healthy 6-year-old ask the nurse for advice about preventing obesity in their child. Which response reflects health promotion?
- A. Limit screen time and encourage outdoor play.'
- B. Weigh your child monthly to monitor for weight gain.'
- C. Give your child a multivitamin daily to prevent obesity.'
- D. Have your child's cholesterol checked annually.'
Correct Answer: A
Rationale: For a healthy 6-year-old, health promotion prevents obesity by fostering active habits limiting screen time and encouraging outdoor play boosts physical activity, burning calories and building muscle, key to avoiding weight gain at this age. Evidence links sedentary screen hours to childhood obesity; play counters it, aligning with nursing's focus on lifestyle over surveillance. Monthly weighing is secondary, tracking not preventing, and may stress the child. Multivitamins don't prevent obesity caloric balance does while annual cholesterol checks detect, not avert, issues. The nurse's reply promotes wellness through fun, practical steps like biking or tag tailored to a child's energy, ensuring long-term health without medicalizing a well kid, a cornerstone of pediatric nursing's preventive approach.
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You are the nurse working with an elderly, competent client who refuses a vitamin B injection ordered by the physician. The family insists that this injection be given, and you give it while the client is objecting. Even though the client improves, the client contacts a lawyer. From your knowledge of nursing and the law, you realize that you:
- A. did the right thing because the client improved.
- B. should have had the family put their request in writing.
- C. have commited an assault against the client.
- D. have committed an act of battery against the client.
Correct Answer: D
Rationale: Administering a vitamin B injection to a competent client who refuses it, despite family insistence and subsequent improvement, constitutes battery. Battery is the unlawful physical contact with a person without consent, and in healthcare, consent is a fundamental right for competent adults. The client's objection overrides family wishes, and giving the injection violates autonomy, a core ethical principle. The outcome of improvement doesn't justify the action legally or ethically. Assault involves threatening harm, whereas battery is the act itself, making this the correct classification. Getting family requests in writing or focusing on the outcome doesn't negate the lack of consent. This scenario underscores the importance of respecting patient rights and the legal consequences of disregarding them, even with good intentions.
A client is receiving 115 ml/hr of continuous IVF. The nurse noticed that the venipuncture site was red and swollen. Which of the following interventions would the nurse perform first?
- A. Stop the infusion
- B. Call the attending physician
- C. Slow that infusion to 20 ml/hr
- D. Place a cold towel on the site
Correct Answer: A
Rationale: Stopping the infusion is the nurse's first intervention when observing a red, swollen venipuncture site, as this may indicate phlebitis, infiltration, or infection. Halting the IV prevents further tissue damage or fluid extravasation, prioritizing patient safety. Redness and swelling suggest inflammation or leakage into surrounding tissue, requiring immediate cessation to assess severity and plan next steps, like site relocation or physician consultation. Calling the physician follows assessment, not precedes stopping the infusion, as the nurse acts within scope to mitigate harm first. Slowing the infusion might worsen damage if fluid is already escaping the vein. A cold towel could reduce swelling later but doesn't address the active infusion causing the issue. Stopping the infusion is the critical initial step, enabling evaluation and preventing complications, aligning with nursing's focus on prompt, protective action.
The laboratory reports of a client who underwent a hypophysectomy show an intracranial pressure (ICP) of $20 \mathrm{mmHg}$. Which action made by the client is responsible for this condition?
- A. Drinking lots of water
- B. Eating high-fiber foods
- C. Bending over at the waist
- D. Bending knees when lowering body
Correct Answer: C
Rationale: ICP of 20 mmHg (elevated) post-hypophysectomy is likely from bending over (C), increasing venous pressure to the brain. Drinking (A) or eating fiber (B) don't directly raise ICP. Knee bending (D) is safe. C is correct. Rationale: Bending elevates intracranial venous return, spiking ICP in a fragile post-surgical state, per neurocare principles, unlike neutral activities.
After a week, Mr. Gary's wife said 'If only I insisted an earlier check up, this wouldn't happen' This exemplifies what stage of grieving?
- A. Denial
- B. Anger
- C. Bargaining
- D. Depression
Correct Answer: C
Rationale: If only I insisted is bargaining (C), per Kubler-Ross seeking to undo loss via 'what ifs.' Denial (A) rejects, anger (B) rages, depression (D) despairs. Bargaining reflects guilt-driven deals, making it the correct stage.
The LPN is preparing to administer an injection of vitamin K to the newborn. The nurse should administer the injection in the:
- A. Rectus femoris muscle
- B. Vastus lateralis muscle
- C. Deltoid muscle
- D. Dorsogluteal muscle
Correct Answer: B
Rationale: The vastus lateralis muscle is the preferred site for vitamin K injection in newborns, offering a large, safe muscle mass away from nerves and vessels, standard for intramuscular prophylaxis against hemorrhagic disease. Rectus femoris is smaller, deltoid underdeveloped, and dorsogluteal risky near sciatic nerve. Nurses use this site for efficacy and safety, teaching parents its purpose in clotting support.