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Which of the following should the nurse expect to include in the plan of care to ensure adequate nutrition for a very active, talkative, and easily distractible client who is unable to sit through meals?
- A. Direct the client to his room to eat.
- B. Offer the client nutritious finger foods.
- C. Ask the client's family to bring his favorite foods from home.
- D. Ask the client about his food preferences.
Correct Answer: B
Rationale: Nutritious finger foods allow the client to eat while accommodating their distractibility and activity level.
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Which of the following is appropriate when developing a plan of care for promoting the development of a preschooler? Select all that apply.
- A. Providing anticipatory guidance for parents.
- B. Helping the parents understand their child's behavior.
- C. Identifying deviations from normal growth and development patterns.
- D. Determining the child's future development.
- E. Sending the child to a day care center.
Correct Answer: A,B,C
Rationale: Anticipatory guidance, understanding behavior, and identifying deviations support preschooler development. Predicting future development is not feasible, and daycare is not universally required.
The nurse is caring for a client who has just undergone a colectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Monitor for signs of bowel perforation.
- B. Encourage early ambulation.
- C. Administer oral fluids immediately.
- D. Keep the client on bed rest for 48 hours.
Correct Answer: B
Rationale: Encouraging early ambulation post-colectomy prevents complications like ileus and deep vein thrombosis.
The nurse recognizes that a client with pain disorder is improving when the client says which of the following?
- A. I need to have a good cry about all the pain I've been in and then not dwell on it.'
- B. I need to find another physician who can accurately diagnose my condition.'
- C. The pain medicine that you gave me helps me to relax.'
- D. I'm angry with all of the doctors I've seen who don't know what they're doing.'
Correct Answer: A
Rationale: Expressing a desire to process emotions and move forward indicates improved coping, a sign of progress in managing pain disorder.
A young adult is hospitalized with a seizure disorder. The client, who is in a bed with padded side rails, has a tonic-clonic seizure. In what order should the nurse take the following actions?
- A. Loosen clothing around the client's neck.
- B. Turn the client on his or her side.
- C. Clear the area around the client.
- D. Suction the airway.
Correct Answer: C,B,A,D
Rationale: First, clear the area to prevent injury, turn the client on their side to maintain airway patency, loosen clothing to ease breathing, and suction if needed to clear secretions.
A client with a history of peptic ulcer disease is prescribed sucralfate (Carafate). The nurse should instruct the client to:
- A. Take the medication 1 hour before meals.
- B. Take the medication with meals.
- C. Take the medication at bedtime.
- D. Stop the medication if constipation occurs.
Correct Answer: A
Rationale: Sucralfate should be taken 1 hour before meals to coat the stomach lining and protect ulcers.