eaq for nclex custom quiz
A school nurse is teaching a class of school-age children about bicycle safety. The nurse determines that a child needs further teaching when the child states: 1 "I will always wear a helmet and ride with traffic facing me." 2 "I will always wear a helmet and walk my bike to cross busy streets." 3 "I will always wear a helmet and keep as close to the curb as possible." 4 "I will always wear a helmet and stay in a single file when I ride with my friends."
"I will always wear a helmet and ride with traffic facing me." Bicyclists are required to follow the rules of the road; they must ride with traffic, obey traffic signs and lights, and signal when turning. Walking the bicycle at intersections, riding close to the curb, and staying in single file all help prevent accidents.
Which statement made by a client after attending a class on nutrition indicates an understanding of the importance of essential amino acids? 1 "Amino acids can be made by the body because they are essential to life." 2 "They come from the diet because they cannot be synthesized in the body." 3 "They are used in key processes essential for growth once they are synthesized by the body." 4 "Essential amino acids are required for metabolism, whereas the other amino acids are not."
"They come from the diet because they cannot be synthesized in the body. The body does not synthesize these amino acids; they must be ingested in the diet. The essential amino acids cannot be made by the body. All amino acids are needed for metabolism; however, arginine and histidine are necessary for growth, but not during adulthood. Essential amino acids cannot be synthesized by the body.
A client comes for an annual physical examination. To provide appropriate nutritional counseling, the nurse calculates the client's body mass index (BMI). The client's weight is 65 kg and the height is 1.7 meters. What is the client's BMI? Record your answer using one decimal place.
22.5 The formula for BMI is: weight in kg ÷ (height in meters)2. The square of the client's height is 1.7 × 1.7 = 2.89; 65 ÷ 2.89 = 22.5. The desirable BMI for adults is 18.5 to 24.9. Study Tip: Develop a realistic plan of study. Do not set rigid, unrealistic goals.
The school nurse is planning to teach a class about nutrition and recommend healthy snacks and food choices to children. Which age group will be most receptive to this information? 1 6-year-old children 2 8-year-old children 3 11-year-old children 4 15-year-old children
8-year-old children Eight-year-old children are beginning to achieve a sense of industry and accomplishment. They are in Piaget's stage of concrete operations, wherein they are able to use their thought processes to experience actions. Their growing independence enables them to base decisions on what they have learned. Six-year-old children are just beginning to experience the developmental goals of the school-aged child. They are not ready to base choices on what they have learned. Preadolescents are beginning to assert their independence and probably will rebel if taught what they should eat. Adolescents need to conform to their peer group; what is learned in a nutrition class probably will be ignored in favor of preestablished preferences.
A 1-year-old infant is brought to the pediatric clinic for the first time. During the assessment the nurse suspects a developmental delay. What developmental milestone should have been achieved by this age? 1 Saying six words 2 Responding to peek-a-boo 3 Building a tower of two cubes 4 Pointing to things when they are named
Responding to peek-a-boo Typically infants respond to social play by 10 months of age. A six-word vocabulary, and building a two-cube tower are typical of a 15-month-old. The child pointing to objects when they are named is typical of a child at 2 years of age.
The nurse has taught newborn care and safety to a group of expectant mothers. Which statement by a mother indicates the need for additional teaching? 1 "I need to put my baby to bed on his back." 2 "I need to toddler-proof my house before the baby starts to walk." 3 "My baby could choke on any small object that will fit in her mouth." 4 "I'll keep my baby in a backward-facing car seat until he's a year old."
"I'll keep my baby in a backward-facing car seat until he's a year old." New guidelines recommend keeping a child in a backward-facing car seat until 2 years of age. Putting a baby to bed on his or her back will reduce the risk of sudden infant death syndrome. The house should be toddler-proofed when the child starts crawling. Choking is a major hazard for the young infant, who will place anything at hand in his or her mouth.
A nurse is making room assignments on the pediatric unit. Who is the best choice of roommate for a 10-year-old boy with juvenile idiopathic arthritis? 1 An 11-year-old girl with colitis 2 A 10-year-old boy with asthma 3 A 10-year-old girl with a fractured femur 4 An 11-year-old boy who has undergone splenectomy
An 11-year-old boy who has undergone splenectomy An 11-year-old boy who has undergone a splenectomy is an appropriate roommate. Ten-year-old boys prefer the company of children of the same sex and age group; also, the child should avoid stressful situations that may increase the likelihood of an exacerbation. Same-sex roommates are more desirable for companionship and will better satisfy the desire for boy/girl separateness of this age group. Children with asthma may have severe respiratory difficulties; this may be too stressful for the child who needs rest.
After surgery a 2-month-old infant is returned to the pediatric unit with an intravenous infusion running and a nasogastric tube in place. What is the initial nursing action? 1 Assessing the infant's status 2 Giving the infant a mild sedative 3 Connecting the nasogastric tube to wall suction 4 Placing the intravenous tubing through an infusion pump
Assessing the infant's status Assessment, the first step of the nursing process, is the priority because it influences all future interventions. The infant's respiratory status and vital signs should be assessed before a sedative is administered. Although it is important to attach the nasogastric tube to a suction device, this may be done after the infant's status has been assessed. Although it is important to connect the IV line to a pump, this may also be done after the infant's status has been assessed.
The nurse prepares to discharge a newborn from the hospital. Which action taken by the father indicates an understanding of the nurse's education regarding car seat safety? The father places the infant in the: 1 Back seat, facing forward 2 Front seat, facing forward 3 Front seat, facing backward 4 Back seat, facing backward
Back seat, facing backward Children younger than 2 years should be placed in a rear-facing car seat secured in the back seat. Placing young children in the front seat is dangerous and could even be fatal if the air bag deploys. Once the child weighs 35 to 40 lb, a front-facing car seat may be used. Children should sit in the backseat until they are 13 years old.
A 5-year-old child is admitted to the pediatric unit in preparation for surgery. On what developmental fears should the nurse base care for this child? 1 Lack of safety and dying 2 Body mutilation and the unknown 3 Darkness and separation from parents 4 Loss of control and interruption of social relationships
Body mutilation and the unknown Body mutilation and fear of the unknown are the typical fears of the preschooler. Lack of safety and dying are the typical fears of the school-age child. Darkness and separation from parents are the typical fears of the toddler. Loss of control and interruption of social relationships are the typical fears of the adolescent.
A nurse taking calls at a local crisis center hotline receives a telephone call from a suicidal adolescent. The nurse can safely terminate the call when the client: 1 Wishes to terminate the conversation 2 Has responded to the nurse's initial assessment of suicide risk 3 Begins repeating the same information that has already been discussed 4 Can state a preventive plan of action for dealing with self-destructive behaviors
Can state a preventive plan of action for dealing with self-destructive behaviors The client should be able to state specific behaviors that can be used to decrease self-destructive thoughts and actions; the client must be empowered. Terminating the conversation is ineffective because the client may end the conversation and remain suicidal. The nurse may gather data through the suicide risk assessment tool, but the client may not have attained catharsis; therefore the dialogue should be continued until a contract has been set or self-destructive behaviors have diminished. Repeating the same information that has already been discussed is an indication that the nurse should help the client focus on life and not on suicide; the client has not yet attained catharsis.
The nurse is teaching a class about nutrition to a group of adolescents. Taking into consideration the prevalence of overweight teenagers, what is the best recommendation the nurse can make? 1 Join a gym. 2 Drink fewer diet sodas. 3 Decrease fast food intake. 4 Take a multivitamin daily.
Decrease fast food intake. Eating a variety of healthful foods instead of a fast-food diet that is high in fat and carbohydrates helps decrease excess weight and increase energy with which to engage in physical activities. Joining a gym is expensive and unnecessary. Physical activity can be achieved in the schoolyard or at home. A multivitamin will not promote weight loss. Vitamins and minerals are best obtained in a balanced diet. Diet soft drinks do not contribute to obesity.
A 2-month-old infant is admitted to the pediatric unit for observation after an automobile collision. Family members are unable to stay. How can the nurse best provide psychological comfort for the infant? 1 Assigning the same nurse to the infant 2 Following a routine to which the infant is accustomed 3 Having the infant listen to the parents' voices over the phone 4 Ensuring that a staff member stays with the infant at all times
Following a routine to which the infant is accustomed Very young infants gain security from having their needs met consistently. Assigning one nurse to care for the infant is ideal but unrealistic. It is not critical at this age because the infant does not yet seek security from a significant caregiver. Although the infant may recognize the parents' voices, having the parents phone the child will not ensure psychological comfort. Consistent observation is adequate.
A school nurse is teaching a unit on nutrition to a sixth-grade class. Why should the nurse include that eating in fast-food restaurants should be limited? 1 Eating is rushed. 2 Portions are too large. 3 Food is high in calories. 4 Sanitation is inadequate.
Food is high in calories. The American Dietetic Association has indicated that the food in fast-food restaurants is calorie dense and higher in fat, sugar, and sodium than the food served at home or in other restaurants. Although fast-food restaurants encourage patrons to eat quickly, this is not the major reason that their food is discouraged. Portions in fast-food restaurants are not large; they are smaller than those in diners and many other restaurants. Fast-food restaurants encourage safe food handling to meet the standards of local health departments.
During a parenting class a nurse is discussing infant/toddler nutrition and ways to reduce the risk of food allergies. What food item should the nurse recommend that the parents avoid until their children are 3 years old? 1 Cow's milk 2 Soy products 3 Peanut butter 4 Chocolate candy
Peanut butter Peanut allergies tend to be very severe. To reduce the risk of peanut allergies, parents should delay their introduction into the diet until the gastrointestinal tract has matured. Cow's milk is introduced after 1 year. Chocolate may be introduced after the first year of life. Although often considered hypoallergenic, soy products can cause food allergies. However, because of the infrequency of soy in the American diet its entry is not delayed after the first year.
A 4-month-old infant is admitted to the pediatric unit. How does the primary nurse expect the infant to behave when approached? 1 Smile socially in recognition of the nurse 2 Cry when the nurse approaches for the first time 3 Reach out to the nurse for the attention that is being offered 4 Cling to the mother when the nurse tries to establish contact
Reach out to the nurse for the attention that is being offered The infant has not yet recognized boundaries between self and mother and is not particular about who meets and resolves needs. The infant is most likely reaching out for attention. A social smile does not indicate recognition of a specific person, only a human face. The infant does not yet differentiate familiar faces from those of strangers. The infant does not understand or fear separation from the mother yet.
A nurse is teaching a community class about campfire safety. A class participant asks about what to do if a person catches on fire. How should the nurse respond? 1 "Remove the person's burning clothing." 2 "Slap the flames with your hands." 3 "Roll the person in the grass." 4 "Pour cold liquid over the flames.
Roll the person in the grass." Rolling the person in the grass effectively extinguishes the flames by eliminating oxygen that supports the flames. Removing burning clothes may protect the person from a more extensive burn injury, but it may further injure the burned tissue. Slapping flames with the hands does not eliminate the oxygen that supports the flames and may, in fact, fan the flames. Pouring cold liquid over the flames may extinguish the flames, but it is not as quick and effective as rolling in the grass.
A nurse in the pediatric clinic discusses the nutrition and feeding needs of an 18-month-old toddler with the child's parents. What information should the nurse include? 1 Growth rate increases, so more protein is needed per pound of body size. 2 Energy requirements become so high that more calories are needed to meet them. 3 Struggling for autonomy may involve refusal of food, but they will eat the amount they need. 4 Three meals a day should be offered, with no between-meal snacks, because they are finicky eaters.
Struggling for autonomy may involve refusal of food, but they will eat the amount they need. A toddler's increasing mobility and growing independence affects eating behaviors; slowed physical growth at this age requires relatively fewer calories. A toddler's growth rate and energy requirements decrease compared with the first year of life. Nutritious snacks between meals should be encouraged if the toddler is not eating adequate meals.
A 5½-month-old infant is admitted to the pediatric unit with a fever and a 48-hour history of vomiting. What assessments will be are most helpful in the development of a plan of care? Select all that apply. 1 Vital signs 2 Urine output 3 Tissue turgor 4 Daily weights 5 Neurological status
vital signs urine output daily weights A baseline assessment of vital signs is essential in the planning of care. The amount of weight lost correlates directly with the degree of dehydration. Assessment of skin turgor is subjective and not as accurate as other options. Urine output is an indicator of kidney function, and this child is likely experiencing dehydration. The neurological status is not expected to be pathologic with dehydration.
A nurse on the pediatric unit is assigned to care for a 2-year-old child with a history of being physically abused. The nurse expects the child to: 1 Smile readily at anyone who enters the room. 2 Be wary of physical contact initiated by anyone. 3 Begin to scream when the nurse nears the bedside. 4 Pay little attention to the nurse standing at the bedside
Be wary of physical contact initiated by anyone. This child will distrust any approach because approaches by adults commonly result in pain; abused children remain alert in an attempt to ward off an attack. This child will not be open to an approach by a stranger; basic trust of others does not develop in abused children. Abused children will usually not cry out; they learn not to expect comforting or soothing by others. This child will be acutely aware of anyone coming near; abused children try to defend themselves by keeping alert to the possibility of attack.
The nurse in the pediatric clinic is assessing the gross motor skills of a 5-year-old child. According to the principles of developmental direction, in which order do these skills develop? Begin with the skill that is accomplished first. 1. Riding a tricycle 2. Walking backward 3. Climbing up and down stairs 4. Skipping and hopping on one foot
Climbing up and down stairs Riding a tricycle Skipping and hopping on one foot Walking backward Muscle coordination and equilibrium improve as the neuromuscular system matures. Gross motor skills progress from the simplest to the most complex. The 2-year-old toddler can climb up and down steps. The 3-year-old child can ride a tricycle. The 4-year-old child can skip and hop on one foot. The 5-year-old child can walk backward.
A 1-year-old child is found to have nutritional iron-deficiency anemia. What nursing interventions are most important in the care of an infant with iron-deficiency anemia? Select all that apply. 1 Conserving the infant's energy 2 Protecting the infant from infection 3 Teaching the parents about nutrition 4 Telling the parents to offer small, frequent feedings 5 Instructing the parents to increase the amount of milk offered
Conserving the infant's energy Protecting the infant from infection Teaching the parents about nutrition Conservation of energy is important because anemic children are usually fatigued. There are inadequate amount of red blood cells (RBCs) and hemoglobin to carry oxygen to body cells. Anemic children are prone to infection. Parents should know which foods are high in iron. Iron promotes the formation of RBCs. The time and amount of feedings are not as important as the quality of foods that are offered. Usually anemia results from drinking unfortified milk and little else; there should be an increase in the variety and quality of the foods offered.
A nurse is caring for a 4-year-old child in the pediatric unit. What does the nurse expect concerning the behavior of a preschooler during hospitalization? 1 Refusing to cooperate with nurses during the parents' absence 2 Demonstrating despair if the parents do not visit at least once a week 3 Crying when the parents leave and return but not during their absence 4 Avoiding interacting and playing with peers in the playroom if other parents are present
Crying when the parents leave and return but not during their absence Preschoolers can tolerate brief periods of separation from their parents; however, emotions associated with separation and perhaps anger at being left are difficult to hide when the parents arrive or leave. Preschoolers usually are quite docile and cooperative because they are afraid of being totally abandoned. The child will demonstrate despair long before the week is over. The presence of other children's parents in the playroom does not discourage them from playing with their peers. Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer.
A 4-year-old child is admitted to the pediatric unit with a tentative diagnosis of acute lymphocytic leukemia (ALL). The mother states that changes in her child's behavior and the "black and blue" marks were noticed several days ago. She blames herself for not bringing her child to the clinic sooner. On what information about the pathophysiology of leukemia should the nurse base a response? 1 The diagnosis can be certain only after a blood smear is analyzed. 2 If leukemia is diagnosed, the child's prognosis is probably guarded. 3 Early signs and symptoms of leukemia are similar to those of other mild illnesses of childhood. 4 The description of the clinical findings indicates that the child has been ill for longer than a single week.
Early signs and symptoms of leukemia are similar to those of other mild illnesses of childhood. To allay parental guilt and anxiety, it is important to acknowledge how difficult it is to recognize severe illness on the basis of changes in the child's behavior and ecchymoses that can result when a child bangs into an object, a common occurrence in young children. A bone marrow aspiration or biopsy is required for a definitive diagnosis. ALL in children has a favorable prognosis, depending on several factors, including the child's age at diagnosis, the white blood cell count, and the type of cell involved. Even if the mother missed the fact that her child was so ill, mentioning this may cause more anxiety and guilt and interfere with the development or a nurse-client rapport.
A 4½-year-old child is admitted to the pediatric unit in preparation for surgery. What psychological responses to hospitalization does the nurse anticipate from this preschooler? Select all that apply. 1 Sadness about leaving playmates 2 Confusion about why surgery is needed 3 Anxiety regarding parental abandonment 4 Fearfulness regarding intrusive procedures 5 Misgivings about being punished for a misdeed
Fearfulness regarding intrusive procedures Misgivings about being punished for a misdeed Preschoolers are developing a concept of their bodies and its boundaries and are more threatened by intrusive procedures than are children in other age groups. Preschoolers are developing a conscience and frequently inappropriately associate occurrences as punishment for perceived misbehavior. Friends are important to school-aged children and adolescents because they need approval and feedback from their peers. Preschoolers are able to understand simple explanations that dispel confusion. Feelings of abandonment are more appropriate for a toddler.
The nurse is teaching a group of parents of toddlers in the daycare center about accident prevention. The nurse determines that more teaching is needed when one parent states: 1 "I'll keep medications in a kitchen cabinet." 2 "I'll put baby gates at the top and bottom of the stairs." 3 "I'll have my daughter in a regular bed by the time she's 2½." 4 "I'll buy my son shoes that close with Velcro instead of laces."
I'll keep medications in a kitchen cabinet." The kitchen cabinet is not a safe place for medications; toddlers are curious and are capable of climbing and opening cabinets. They must be protected from dangerous areas such as stairs. Secured gates at the top and bottom of stairs provide a barrier. At a height of 36 inches a toddler is ready to use a bed; the average toddler reaches this height at age 2½ years. Shoes with Velcro can be secured without the need for shoelaces, which may become untied and pose a risk for falls.
On a routine visit to the well-child clinic, the parents of a 3-year-old child tell the nurse that their child is a "picky" eater and express concern about their child's nutritional status. What should the nurse suggest to help the parents meet the child's nutritional requirements? 1 Including some of the foods the child prefers in every meal 2 Cooking nutritious meals and staying with the child until the food is eaten 3 Serving a regular diet to the family and a special meal that the child will eat 4 Explaining that there will be no dessert until the child eats the food on the plate
Including some of the foods the child prefers in every meal By including some of the nutritious foods that the child prefers in every meal, the parents can ensure that the child's nutritional status will be maintained or improved. Insisting that the child eat what is prepared will result in a battle for control between the toddler and the parent, which is nontherapeutic. Fixing two meals is not appropriate because it draws attention to the toddler's eating habits. Dessert should not be used for disciplinary control; as the child gets older, dessertlike food may take on too much significance.
A nurse who volunteers in a daycare for preschoolers has been asked to give a presentation to parents about health promotion. Which topics should the nurse include? 1 Nutrition and bullying 2 Injury prevention and dental health 3 Organized sports and immunizations 4 Toilet-training and attention deficit disorde
Injury prevention and dental health Preschoolers are at risk for injury because of their increasing independence, and dentition issues are important because of the need to preserve the primary teeth until it is time for permanent teeth to erupt. Nutrition and bullying are more appropriate topics for school-aged children. Most preschoolers are not developmentally ready for organized sports. Toilet training is an appropriate topic for toddlers. Children are expected to be toilet-trained by the time they reach preschool age.
A nurse is teaching parenting to a group of teenage mothers. After a discussion of child safety, the young mothers provide feedback. Which comment indicates the need for additional information? 1 "My baby could drown if I leave her alone in water higher than her waist." 2 "My baby could swallow any item small enough for him to put in his mouth." 3 "My baby will be safest in the car if I put the car seat in the middle of the back seat." 4 "My baby will touch everything when she starts to crawl, so I'll cover all of the electrical outlets."
My baby could drown if I leave her alone in water higher than her waist." Drowning can occur in even a minimal amount of water because the infant does not have the body control to move out of the water. Babies can swallow any small item left in their reach. The middle of the back seat is the best location for the car seat. Before the infant becomes mobile, the mother will need to take precautions to prevent electrical injury.
A nurse is teaching a prenatal class about infant safety. After the class several of the students are heard discussing what they have learned. The nurse determines that the teaching has been effective when one of the future parents states: 1 "My mother has already made the cutest pillowcases for the baby's pillows." 2 "I just bought a new baby seat that can be strapped into the front seat of the car." 3 "My mother can't believe that babies are supposed to sleep on their backs, not their stomachs." 4 "At my shower I was given a baby tub that has a special safety strap that lets me leave the baby alone in it."
My mother can't believe that babies are supposed to sleep on their backs, not their stomachs. Research demonstrates that placing an infant on the back reduces the incidence of sudden infant death syndrome (SIDS). Pillows in an infant's crib can cause suffocation. It is unsafe to strap an infant seat into the front seat of a car. An infant can drown in a very small amount of water in a tub; it is unsafe to leave an infant alone in a tub.
A hyperactive 9-year-old child with a history of attention deficit-hyperactivity disorder is admitted for observation after a motor vehicle collision. On what should nursing actions be focused when the nurse is teaching about personal safety? 1 Requesting that the child write at least three safety rules 2 Asking the child to verbalize as many safety rules as possible 3 Talking with the child about the importance of using a seat belt 4 Encouraging the child to talk with other children about their opinions of safety rules
Talking with the child about the importance of using a seat belt
A nurse in the pediatric clinic is assessing the fine motor skills of a 5-year-old child. According to the principles of developmental direction, in which order does a child develop these skills? Begin with the skill that is accomplished first. 1. Uses scissors 2. Turns a doorknob 3. Copies a square on a piece of paper 4. Places objects into a narrow-necked bottle
Turns a doorknob Places objects into a narrow-necked bottle Uses scissors Copies a square on a piece of paper At 2 years a toddler can coordinate the fingers, hands, and wrists to turn objects such as doorknobs. At 3 years children have the hand-eye coordination to place small objects in a narrow space. At 4 years children can manipulate the fingers so as to use scissors effectively. At 5 years children's fine motor coordination improves, enabling them to move from copying a circle (age 4) to copying a square
The nurse teaches a group of clients that nutritional support of natural defense mechanisms indicates the need for a diet high in: 1 Essential fatty acids 2 Dietary cellulose and fiber 3 Tryptophan, an amino acid 4 Vitamins A, C, E, and selenium
Vitamins A, C, E, and selenium Vitamins A, C, E, and selenium stimulate the immune system. The role of fatty acids in natural defense mechanisms is uncertain. Dietary cellulose and fiber have no known effect on natural defense mechanisms. Tryptophan has no known effect on natural defense mechanisms.
A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. What infant safety education should be provided? Select all that apply. 1 Wash your hands before touching the newborn. 2 Send the newborn to nursery to be monitored during the night. 3 All client identification bands should remain in place until discharge. 4 Do not let anyone remove the infant from your sight while you are in the hospital. 5 Check the identification of staff and if there is a question of validity, call the nursing station.
Wash your hands before touching the newborn. All client identification bands should remain in place until discharge. Check the identification of staff and if there is a question of validity, call the nursing station. Mothers, significant others or persons of the mother's choice, and the infant must continue to wear identification bands during the entire hospital stay. These bands show which baby belongs to which mother. The mother should call the nursing station to verify any person appearing to be staff if she has any question about who the person is. Proper identification must be worn by staff at all times. Washing hands before touching the newborn will decrease the chance of infectious transfer of microorganisms to newborn. Safety is the most important concern. There may be times when procedures, assessments, showering, and other activities involve the newborn's being taken from the mother's room. Only well-identified staff members caring for the client should be allowed to take infant out of the mother's sight. It is not necessary to send the newborn to the nursery during the night; the mother may keep the baby at her side during this time.
A nurse on the pediatric unit is planning recreational activities for a 4-year-old with an exacerbation of nephrotic syndrome. What are the most appropriate activities, in light of the child's developmental level and physical status? 1 Riding a tricycle and playing with large blocks 2 Watching cartoon videos and listening to stories 3 Reading animal stories and playing video games 4 Leading a pull toy and playing with a map puzzle
Watching cartoon videos and listening to stories Enjoyment of fantasy and listening to stories are quiet, pleasurable pastimes for a 4-year-old. Riding a tricycle requires too much energy, and playing with large blocks is below a 4-year-old child's developmental level. Although preschool children may enjoy video games, they are not expected to be able to read for enjoyment. The pull toy is below a 4-year-old child's developmental level, and a map puzzle is too advanced.
Discharge teaching for a client with hypercholesterolemia includes nutritional instructions for a diet low in saturated fat. Which items included by the client on a list of foods to avoid supports the nurse's conclusion that teaching has been effective? 1 High-fiber foods 2 Canned vegetables 3 Citrus fruits and juices 4 Whole milk and hard cheeses
Whole milk and hard cheeses Milk and milk products are high in fat and should be limited to reduce cholesterol levels. High-fiber foods are beneficial and should be encouraged. Canned vegetables have no fat. Citrus fruits have no fat and should be encouraged.
A toddler on the pediatric unit is required to have temporary dietary restrictions after colorectal surgery. What is the best way for the nurse to promote adherence to the restrictions? 1 By limiting restrictions to nonessential foods 2 By handling dietary changes in a matter-of-fact way 3 By having the dietitian explain the restrictions to the parents 4 By arranging to have an adult other than a parent stay at mealtime
by handling dietary changes in a matter of fact way Toddlers are ritualistic and do not tolerate change well; any change in diet should be done matter-of-factly. Because of their characteristic struggle for autonomy, toddlers should not be forced to eat. Limited restrictions on nonessential foods are not always possible. Although the parents should consult with the dietitian, this will not affect the toddler's response to the dietary restrictions. The toddler is still dependent on the parents and therefore will respond better to them than to a stranger.
Health promotion efforts within the health care system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? Select all that apply. 1 Encouraging regular dental checkups 2 Facilitating smoking cessation programs 3 Administering influenza vaccines to older adults 4 Teaching the procedure for breast self-examination 5 Referring clients with a chronic illness to a support group
encouraging regular dental check ups teaching the procedure for breast self-examination Encouraging regular dental checkups is a secondary prevention activity because it emphasizes early detection of health problems, such as dental caries and gingivitis. Teaching the procedure for breast self-examination is a secondary prevention activity because it emphasizes early detection of problems of the breast, such as cancer. Facilitating smoking cessation programs is a primary prevention activity because it emphasizes health protection against heart and respiratory diseases. Administering influenza vaccines to older adults is a primary prevention activity because it emphasizes health protection against influenza. Referring clients with a chronic illness to a support group is a tertiary prevention activity because it emphasizes care that is provided after illness already exists.
A dehydrated infant with a several-day history of vomiting is admitted to the pediatric unit with the diagnosis of gastroenteritis. The nurse plans to monitor the infant's response to parenteral therapy. What is the best indicator of rehydration? 1 Increased weight 2 The number of wet diapers 3 Decreased central venous pressure 4 The record of higher intake than output
increased weight An increase in body weight is the most reliable and objective indicator for assessment of rehydration; 1 L of fluid is equal to approximately 2.2 lb. Counting the number of wet diapers and weighing wet diapers are not accurate measures of the effectiveness of rehydration therapy; they provide an approximate measure of output. With rehydration the central venous pressure will increase as the hypovolemia is corrected; direct central venous pressure monitoring is too invasive an intervention for this infant. Although intake and output should be measured, this is not as reliable an indicator of hydration status as are daily weighings.