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Which of the following examples should the nurse use to describe bulimia to a group of parents at a local community center?
- A. An adolescent male who uses calorie-counting to maintain his weight in the desirable range for his height.
- B. A college-age male who uses regular exercise to be able to eat and drink what he wants without gaining weight.
- C. A middle-aged female who uses diet pills occasionally to help her lose 10 lb.
- D. A college-age female who binges and then purges to prevent weight gain.
Correct Answer: D
Rationale: Bulimia is characterized by binge eating followed by purging to prevent weight gain.
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You are planning discharge education for your client who has a new colostomy. Which complication of a colostomy should you educate this client about?
- A. A prolapsed stoma
- B. A vitamin B12 deficiency
- C. Nocturnal enuresis
- D. GI stone formation
Correct Answer: A
Rationale: A prolapsed stoma is a potential complication of a colostomy, and clients should be educated to recognize and report it.
A client is admitted with severe abdominal pains and the diagnosis of acute pancreatitis. The nurse should develop a plan of care during the acute phase of pancreatitis that will involve interventions targeting which of the following problems?
- A. Drug and alcohol abuse.
- B. Risk for injury.
- C. Severe pain.
- D. Ineffective airway clearance.
Correct Answer: C
Rationale: Severe pain is a primary concern in acute pancreatitis, requiring targeted interventions like analgesics.
The nurse is teaching a client with a new diagnosis of asthma about the use of a peak flow meter. Which of the following instructions is most important?
- A. Use the meter once a week.
- B. Record the highest of three readings.
- C. Clean the meter with soap daily.
- D. Use the meter only during an asthma attack.
Correct Answer: B
Rationale: Recording the highest of three readings provides an accurate measure of peak expiratory flow to monitor asthma control.
A client with a history of cardiac problems is having severe chest pain. What should be nurse's first response?
- A. Notify the physician
- B. Administer an analgesic to control the pain
- C. Assess the client's pain
- D. Start oxygen at 2L minute via nasal cannula
Correct Answer: C
Rationale: Assessing the client's chest pain is the first step to determine its nature and severity, guiding further actions like notifying the physician or administering oxygen or analgesics.
The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the highest priority to prevent ventilator-associated pneumonia?
- A. Performing oral care every 4 hours.
- B. Elevating the head of the bed to 30-45 degrees.
- C. Administering prophylactic antibiotics.
- D. Suctioning the endotracheal tube every 2 hours.
Correct Answer: B
Rationale: Elevating the head of the bed to 30-45 degrees reduces the risk of aspiration, a key factor in preventing ventilator-associated pneumonia.