A teen hospitalized with anorexia nervosa is now permitted to leave her room and eat in the dining room. Which of the following nursing interventions should be included in the client’s plan of care?
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Solution
Answer B is correct. Having a staff member remain with the client for 1 hour after meals will help prevent self-induced vomiting. Answer A is incorrect because the client will weigh more after meals, which can undermine treatment. Answer C is incorrect because the client will need a balanced diet and excess protein might not be well tolerated at first. Answer D is incorrect because it treats the client as a child rather than as an adult.
Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should:
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Solution
Answer A is correct. Providing additional fluids will help the newborn eliminate excess bilirubin in the stool and urine. Answer B is incorrect because oils and lotions should not be used with phototherapy. Physiologic jaundice is not associated with infection; therefore, answers C and D are incorrect.
An 8-year-old is admitted with drooling, muffled phonation, and a temperature of 102°F. The nurse should immediately notify the doctor because the child’s symptoms are suggestive of:
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Solution
Answer B is correct. The child’s symptoms are consistent with those of epiglottitis, an infection of the upper airway that can result in total airway obstruction. Symptoms of strep throat, laryngotracheobronchitis, and bronchiolitis are different than those presented by the client; therefore, answers A, C, and D are incorrect.
Which instruction should be included in the discharge teaching for the client with cataract surgery?
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Solution
Answer B is correct. The eye shield should be worn at night or when napping, to prevent accidental trauma to the operative eye. Prescription eyedrops, not over-the-counter eyedrops, are ordered for the client; therefore, Answer A is incorrect. The client might or might not require glasses following cataract surgery; therefore, answer C is incorrect. Answer D is incorrect because cataract surgery is pain free.
A client has returned to his room following an esophagoscopy. Before offering fluids, the nurse should give priority to assessing the client’s:
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Solution
Answer B is correct. The client’s gag reflex is depressed before having an EGD. The nurse should give priority to checking for the return of the gag reflex before offering the client oral fluids. Answer A is incorrect because conscious sedation is used. Answers C and D are not affected by the procedure; therefore, they are incorrect.
A client admitted to the psychiatric unit claims to be the Son of God and insists that he will not be kept away from his followers. The most likely explanation for the client’s delusion is:
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Solution
Answer C is correct. Delusions of grandeur are associated with low self-esteem. Answer A is incorrect because conversion is expressed as sensory or motor deficits. Answers B and C can cause an increase in the client’s delusions but do not explain their purpose; therefore, they are incorrect.
Which statement describes the contagious stage of varicella?
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Solution
Answer D is correct. The contagious stage of varicella begins 24 hours before the onset of the rash and lasts until all the lesions are crusted. Answers A, B, and C are inaccurate regarding the time of contagion; therefore, they are incorrect.
A client is admitted with a diagnosis of hypothyroidism. An initial assessment of the client would reveal:
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Solution
Answer B is correct. Symptoms of hypothyroidism include weight gain, lethargy, slow speech, and decreased respirations. Answers A and D do not describe symptoms associated with myxedema; therefore, they are incorrect. Answer C describes symptoms associated with Graves’s disease; therefore, it is incorrect.
A child with croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the tent is to:
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Solution
Answer D is correct. The primary reason for placing a child with croup under a mist tent is to liquefy secretions and relieve laryngeal spasms. Answer A is incorrect because it does not prevent insensible water loss. Answer B is incorrect because the oxygen concentration is too high. Answer C is incorrect because the mist tent does not prevent dehydration or reduce fever.
A 9-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of polymigratory arthritis?
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Solution
Answer D is correct. The child with polymigratory arthritis will exhibit swollen, painful joints. Answer B is incorrect because it describes subcutaneous nodules. Answer C is incorrect because it describes erythema marginatum. Answer A is incorrect because it describes Syndeham’s chorea.