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When reviewing the assessment data, the nurse would expect to note which characteristic physical finding?
- A. Extremely low body weight
- B. Erosion of dental enamel
- C. Cessation of menstruation
- D. Patchy loss of hair
Correct Answer: B
Rationale: Erosion of dental enamel is caused by frequent vomiting in bulimia.
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Which nursing action is most appropriate at this time?
- A. Postpone weighing the client until later.
- B. Confront the client about the water intake.
- C. Say nothing and weigh the client as usual.
- D. Subtract 2 lb (0.9 kg) from the client's weight.
Correct Answer: A
Rationale: Postponing weighing ensures accuracy and addresses manipulative behavior.
The nurse correctly explains that the behavior the preschooler is demonstrating is based on a need to feel what?
- A. Powerful
- B. Secure
- C. Confident
- D. Dependent
Correct Answer: B
Rationale: Preschoolers seek security in stressful situations.
Of the following suggestions, which one would best prevent nursing personnel from becoming injured when providing the adolescent with care?
- A. Apply soft wrist restraints before ambulating the client.
- B. Ask a parent to care for the client.
- C. Explain steps involved in care before touching the client.
- D. Medicate the client immediately before ambulation.
Correct Answer: C
Rationale: Explaining steps reduces fear and potential for aggressive reactions.
During the initial physical examination, the nurse is most likely to detect which finding related to anorexia?
- A. Growth of fine body hair
- B. Bruises over the upper torso
- C. Hyperactive bowel sounds
- D. Club-shaped fingertips
Correct Answer: A
Rationale: Lanugo (fine body hair) develops in anorexia due to malnutrition.
Which assessment finding would lead the nurse to suspect physical abuse?
- A. The child protests when approached by the nurse.
- B. The child has patchy loss of hair.
- C. The child has a fresh bruise on the forehead.
- D. The child has an abrasion on the right knee.
Correct Answer: C
Rationale: A fresh bruise in an unusual location raises suspicion of abuse.