EAQ

What clinical finding does a nurse expect when assessing a 4-month-old infant with gastroenteritis and moderate dehydration?

Depressed anterior fontanel

A client has a diskectomy and fusion for a herniated nucleus pulposus. When getting out of the bed for the first time since surgery, the client reports feeling faint and lightheaded. What should the nurses assisting with the ambulation have the client do?

it on the edge of the bed so they can hold the client upright.

A 3-year-old preschooler has been hospitalized with nephrotic syndrome. What is the best way for the nurse to evaluate fluid retention or loss?

weighing the child at the same time each day

A mother who is visiting the pediatric clinic with her 10-month-old son tells the nurse how pleased she is with her chubby infant. She exclaims, "Look how much weight he's gained even though he drinks only orange juice! He won't drink any milk!" What is best response by the nurse?

"Let's talk about his nutrition."

A teenager is being discharged with a cast. What should the nurse recommend if the client experiences pruritus around the cast edges?

"Put an ice pack on the affected area."

An infant is to be discharged after surgery for pyloric stenosis. What instructions should the nurse give the parents?

"hold the baby while continuing to feed a regular formula slowly and burp frequently"

After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. What is the nurse's greatest concern at this time?

Addressing the pain

What is the nurse's primary consideration when caring for a client with rheumatoid arthritis?

Comfort

After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. Which need is the primary consideration in the care of this client?

Control of Pain

A nurse is caring for a client with Addison disease. Which information should the nurse include in a teaching plan to encourage this client to modify dietary intake?

Extra salt is needed to replace the amount being lost caused by lack of sufficient aldosterone to conserve sodium.

While a nurse is teaching a client with diabetes about food choices, the client states, "I do not like broccoli." Which food should the nurse suggest to substitute for broccoli?

Green beans

A client is receiving hypertonic tube feedings. What should the nurse consider to be the main reason this client may experience diarrhea?

High osmolarity of the feedings

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?

Including some of the foods the child prefers in every meal

A child has cystic fibrosis. Which verbalization by the parents about their plan for the child's dietary regimen provides evidence that they understand the nurse's instructions?

Provide high-calorie foods between meals.

A nurse is providing postoperative teaching to a client who is scheduled to have an above-the-knee amputation. The client will use crutches during the postoperative period. Which activity will prepare the client for crutch walking?

Lifting weights

A client with hemiparesis is reluctant to use a cane. How does the nurse explain the cane's purpose to the client?

Maintain balance to improve stability

After surgery for a fractured hip, a client states, "I don't remember when I have ever been so uncomfortable." What should the nurse's initial response be?

Perform a complete pain assessment.

Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client?

Removing the catheter within 24 hours

Before administering a nasogastric feeding to a preterm infant, the nurse aspirates a small amount of residual fluid from the stomach. What is the nurse's next action?

Returning the aspirate and subtracting the amount of the aspirate from the feeding

An older client with dementia of the Alzheimer type is residing in a nursing home. When in bed, the client consistently is found sleeping in the semi-Fowler position. What area of the client's body does the nurse determine has the most risk for developing a pressure ulcer?

Sacrum

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client?

Space activities throughout the day.

To prevent skin breakdown on the scalp of an infant with hydrocephalus, how should the nurse position the infant?

Supine, with the head elevated about 45 degrees

How should a nurse intervene when a confused and anxious client voids on the floor in the sitting room of the mental health unit?

Toilet the client more frequently with supervision

A nurse is caring for a 9-month-old infant with severe dehydration. What does the nurse expect to note while completing a physical assessment of this infant?

Weak, rapid pulse

A nurse is preparing a 10-year-old child for a tonsillectomy and adenoidectomy to be performed later in the day. What information should the nurse share with the child?

What the child will experience before and after the procedure

A nurse is teaching the parents of a school-aged child with celiac disease about the nutrients that must be avoided in a gluten-free diet. What nutrients should the nurse teach the parents to avoid?

Wheat and oat products