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Which recommendation by the nurse is most likely to be effective in helping the client control bulimia?
- A. Eat small, frequent meals.
- B. Take a daily inventory of food offered at the dormitory.
- C. Avoid eating in fast food establishments.
- D. Keep a daily calorie count of all foods consumed.
Correct Answer: A
Rationale: Small, frequent meals stabilize eating patterns, reducing the urge to binge and purge, a key strategy in managing bulimia.
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If the client frequently comes to meals with the residue of soap on the face or an unbuttoned shirt, which action by the nurse is most beneficial to the client's emotional state?
- A. Send the client back to finish.
- B. Bathe and dress the client daily.
- C. Schedule the client's hygiene activities after meals.
- D. Comment on how self-reliant the client is.
Correct Answer: C
Rationale: Scheduling hygiene after meals allows assistance without embarrassment, supporting the client's dignity and emotional well-being.
If the client's drug screen is positive for cocaine, it is most appropriate for the nurse to advise a staff person to monitor the client closely for which finding?
- A. Cardiac arrhythmias
- B. Depressed respirations
- C. Low heart rate
- D. Elevated blood glucose level
Correct Answer: A
Rationale: Cocaine's stimulant effects increase the risk of cardiac arrhythmias, a potentially life-threatening complication requiring close monitoring.
The client has been placed in involuntary seclusion. Which assessment observation best indicates to the nurse the client’s readiness to leave involuntary seclusion?
- A. The client calmly stating “I have control over my anger now.”
- B. BP is 110/64 mm Hg; P is 82 bpm and regular; R is 16 bpm and regular.
- C. Client is observed sitting in seclusion room doorway asking staff for a drink.
- D. Medical record states “Seclusion of 45 minutes resulted in improved control.”
Correct Answer: C
Rationale: Sitting in the doorway and requesting a drink (C) shows tolerance to stimuli. Statements (A) vital signs (B) and records (D) are less definitive than observed behavior.
The nurse is preparing to document the client’s violent episode. Which statements should be included specifically about the violent episode? Select all that apply.
- A. Client’s wife called during the escalation cycle.
- B. Client refused to voluntarily enter into seclusion.
- C. Client stated “All of you are just evil people.”
- D. Attempts to identify the cause of client’s agitation failed.
- E. Five staff members responded to “Emergency Code.”
- F. Client asked to leave seclusion room after 30 minutes.
Correct Answer: B ,C, D, F
Rationale: Documentation includes refusal of seclusion (B) client statements (C) failed interventions (D) and reintegration (F). Wife’s call (A) and staff numbers (E) are irrelevant.
The nurse is reviewing the medical records of children who have been abused. Which main common characteristic of parents who abuse children is the nurse most likely to identify?
- A. History of mental illness
- B. Violent behavior patterns
- C. Isolation of parent or family
- D. Parent older than 40 years of age
Correct Answer: C
Rationale: Social isolation (C) is a common trait in abusive families. Mental illness (A) affects ~10% most abusers aren’t overtly violent (B) and abuse links to younger parents (D).