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?
-
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:
-
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:
-
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?
-
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-thecounter 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:
-
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.
Which information should be given to the client taking phenytoin (Dilantin)?
-
Solution
Answer C is correct. Gingival hyperplasia is a side effect of phenytoin. The client will need more frequent dental visits. Answers A, B, and D do not apply to the medication; therefore, they are incorrect.
A client with schizophrenia is receiving chlorpromazine (Thorazine) 400mg twice a day. An adverse side effect of the medication is:
-
Solution
Answer B is correct. Neuroleptic malignant syndrome is an adverse reaction that is characterized by extreme elevations in temperature. Answers A and C are incorrect because they are expected side effects. Elevations in blood pressure are associated with reactions between foods containing tyramine and MAOI; therefore, answer D is incorrect.
Which of the following snacks would be suitable for the child with gluten-induced enteropathy?
-
Solution
Answer B is correct. The client with gluten-induced enteropathy experiences symptoms after ingesting foods containing wheat, oats, barley, or rye. Corn or millet are substituted in the diet. Answers A, C, and D are incorrect because they contain foods that worsen the client’s condition.
Which of the following skin lesions is associated with Lyme’s disease?
-
Solution
Answer A is correct. Lyme’s disease produces a characteristic annular or circular rash sometimes described as a “bull’s eye” rash. Answers B, C, and D are incorrect because they are not symptoms associated with Lyme’s disease.
The client scheduled for electroconvulsive therapy tells the nurse, “I’m so afraid. What will happen to me during the treatment?” Which of the following statements is most therapeutic for the nurse to make?
-
Solution
Answer A is correct. The client will receive medication that relaxes skeletal muscles and produces mild sedation. Answers B and D are incorrect because such statements increase the client’s anxiety level. Nausea and headache are not associated with ECT; therefore, answer C is incorrect.