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While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what other behavior?
- A. Sexual promiscuity
- B. Poor body image
- C. Dropping out of school
- D. Drug experimentation
Correct Answer: B
Rationale: When addressing obesity in adolescents, it is crucial to consider that poor body image is a common behavior associated with obesity. As adolescents gain weight, they may experience a decrease in self-esteem and a negative perception of their body. This can contribute to a cycle of unhealthy behaviors and impact their overall well-being. The other choices are less commonly associated with obesity in adolescents. Sexual promiscuity may be influenced by various factors unrelated to obesity, dropping out of school is more often linked to academic challenges or social issues, and drug experimentation can stem from a range of influences but is not directly correlated with obesity.
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What is the most frequent cause for suicide in adolescents?
- A. Progressive failure to adapt
- B. Feelings of anger or hostility
- C. Reunion wish or fantasy
- D. Feelings of alienation or isolation
Correct Answer: D
Rationale: Feelings of alienation or isolation are the most frequent cause for suicide in adolescents. Adolescents may experience a gradual isolation leading to a loss of meaningful social contacts, which can be self-imposed or result from an inability to express feelings. During this developmental stage, achieving a sense of identity and peer acceptance is crucial. Choices A, B, and C are incorrect: Progressive failure to adapt, feelings of anger or hostility, and reunion wish or fantasy are not typically identified as the primary cause of suicide in adolescents.
The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented?
- A. Watery diarrhea
- B. Ribbon-like stools
- C. Profuse projectile vomiting
- D. Bright red blood and mucus in the stools
Correct Answer: D
Rationale: Intussusception is a condition where a part of the bowel slides into the next section, causing an obstruction. The classic presentation includes severe abdominal pain that is crampy, intermittent, and may cause the child to draw knees to the chest. While vomiting can occur, it is not typically projectile in nature. A key hallmark of intussusception is the passage of bright red blood and mucus in the stools, often described as currant jelly-like. Watery diarrhea and ribbon-like stools are not typical signs of intussusception and should not be expected in a child with this condition.
The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder?
- A. Bile-stained fecal emesis
- B. The passage of currant jelly-like stools
- C. Failure to pass meconium stool in the first 24 hours after birth
- D. Sausage-shaped mass palpated in the upper right abdominal quadrant
Correct Answer: C
Rationale: Imperforate anus is the incomplete development or absence of the anus in its normal position in the perineum. Failure to pass meconium stool within the first 24 hours after birth is a key clinical manifestation associated with this disorder. This finding should prompt further assessment to confirm the suspected diagnosis. Other assessment findings in imperforate anus may include absence or stenosis of the anal rectal canal, presence of an anal membrane, and an external fistula to the perineum. Options A, B, and D describe findings typically noted in intussusception, a different condition characterized by bowel obstruction and telescoping of the intestines that can present with bile-stained fecal emesis, the passage of currant jelly-like stools, and a sausage-shaped mass palpated in the upper right abdominal quadrant.
The infection control nurse is assigned to a patient with osteomyelitis related to a heel ulcer. The wound is 5cm in diameter and the drainage saturates the dressing so that it must be changed every hour. What is her priority intervention?
- A. Place the patient under contact precautions
- B. Use strict aseptic technique when caring for the wound
- C. Place another dressing to reinforce the first one
- D. Elevate the patient's leg to prevent more drainage
Correct Answer: A
Rationale: The priority intervention for a patient with osteomyelitis related to a heel ulcer, with a wound that saturates the dressing every hour, is to place the patient under contact precautions. Contact precautions are essential when managing infectious wounds to prevent the spread of infection to healthcare workers, other patients, and visitors. Strict aseptic technique (Choice B) should always be used with wound care but is secondary to implementing contact precautions in this scenario. Placing another dressing (Choice C) or elevating the patient's leg (Choice D) may be necessary but do not address the immediate need for infection control measures.
What nursing intervention demonstrates that the nurse understands the priority nursing diagnosis when caring for oral cancer patients with extensive tumor involvement and/or a high amount of secretions?
- A. The nurse uses a pen pad to communicate with the patient
- B. The nurse provides oral care every 2 hours
- C. The nurse listens for bowel sounds every 4 hours
- D. The nurse suctions as needed and elevates the head of the bed
Correct Answer: D
Rationale: The correct answer is to suction as needed and elevate the head of the bed. This intervention is crucial for managing Ineffective Airway Clearance, which is the priority nursing diagnosis in oral cancer patients with extensive tumor involvement and/or a high amount of secretions. Suctioning helps clear secretions that may obstruct the airway, while elevating the head of the bed promotes optimal respiratory function. Providing oral care every 2 hours may be important for overall oral health but is not directly related to addressing the priority diagnosis. Listening for bowel sounds every 4 hours is more relevant to gastrointestinal assessment and not specific to managing airway clearance issues in oral cancer patients.