Nokea
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.
You may also like to solve these questions
Which nursing instruction is most appropriate when teaching a client who self-administers haloperidol (Haldol)?
- A. Take the pills on an empty stomach.
- B. Do not skip meals while taking the drug.
- C. Stop taking the drug if sedation occurs.
- D. Rise slowly from a sitting position.
Correct Answer: D
Rationale: Rising slowly prevents orthostatic hypotension, a common side effect.
If this diagnosis is accurate, it is most important for the nurse to assess for which characteristic finding?
- A. The mother is obsessed with the fear that her child will die.
- B. The mother is well versed in normal health patterns among children.
- C. The mother is responsible for creating the child's symptoms.
- D. The mother is overreacting to minor variations in her child's health.
Correct Answer: C
Rationale: Munchausen syndrome by proxy involves a caregiver causing or fabricating symptoms.
If the unprescribed drug is an anabolic steroid, which other physical effect is common?
- A. Decreased lung capacity
- B. Bronzed skin
- C. Occurrence of or worsened acne
- D. Brittle nails
Correct Answer: C
Rationale: Acne is a common side effect of anabolic steroids.
Which assessment finding best indicates that a child taking methylphenidate hydrochloride (Ritalin) is experiencing undesirable side effects?
- A. The child has altered elimination patterns.
- B. The child develops intolerance to certain foods.
- C. The child has an elevated blood pressure.
- D. The child has evidence of skin breakdown.
Correct Answer: C
Rationale: Elevated blood pressure is a concerning side effect of Ritalin.
When the teenager makes an appointment at a birth control clinic, which nursing attribute is most important to communicate during the initial meeting?
- A. Efficiency
- B. Intelligence
- C. Nonjudgmental attitude
- D. Acceptance
Correct Answer: D
Rationale: Acceptance creates a safe space for the teen to discuss sensitive issues.