Nutrition
A nurse provides care for an adolescent patient diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed? a. The nurse interacts with the patient in a protective fashion. b. The nurse's comments to the patient are compassionate and nonjudgmental. c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the patient to a self-help group for individuals with eating disorders.
A
A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis? a. "I am fat and ugly." b. "What I think about myself is my business." c. "I'm grossly underweight, but that's what I want." d. "I'm a few pounds overweight, but I can live with it."
A
An Asian-American expectant father tells the nurse that he seems to be gaining weight, just like his wife. The nurse recognizes that this behavior is most likely a reflection of which? a. Couvade b. Embarrassment c. Ambivalence regarding the pregnancy d. Limited interest in the well-being of his wife
A
An older adult is in the hospital because of heart failure and has become incontinent of urine. Which evidence-based resource should the nurse use to guide continence care for this patient? a. Nursing Standard Practice Protocol b. The Borun Center training modules c. Toolkit from the American Geriatrics Society d. The Centers for Medicare and Medicaid Services
A
An older adult who is on bed rest after surgery is prescribed morphine for pain. Which of the following is the nurse's priority for preventive care? a. Constipation c. Poor solid food intake b. Diarrhea d. Poor liquid intake
A
An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should: a. assess lung sounds and extremities. b. suggest use of an aerobic exercise program. c. positively reinforce the patient for the weight gain. d. establish a higher goal for weight gain the next week.
A
Margaret, a 36-year-old divorcee with a successful modeling career, finds out that her 18-year-old married daughter is expecting her first child. Which is a major factor in determining how Margaret will respond to becoming a grandmother? a. Her age b. Her career c. Being divorced d. Age of the daughter
A
One bed is available on the inpatient eating disorders unit. Which patient should be admitted to this bed? The patient whose weight decreased from: a. 150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9° C; pulse, 38 beats/min; blood pressure 60/40 mm Hg b. 120 to 90 pounds over a 3-month period. Vital signs are temperature, 36° C; pulse, 50 beats/min; blood pressure 70/50 mm Hg c. 110 to 70 pounds over a 4-month period. Vital signs are temperature 36.5° C; pulse, 60 beats/min; blood pressure 80/66 mm Hg d. 90 to 78 pounds over a 5-month period. Vital signs are temperature, 36.7° C; pulse, 62 beats/min; blood pressure 74/48 mm Hg
A
Physical assessment of a patient diagnosed with bulimia often reveals: a. prominent parotid glands. c. thin, brittle hair. b. peripheral edema. d. 25% underweight.
A
Three months ago a patient diagnosed with binge eating disorder weighed 198 pounds. Lorcaserin (Belviq) was prescribed. Which current assessment finding indicates the need for reevaluation of this treatment approach? The patient: a. now weighs 196 pounds. b. says, "I am using contraceptives." c. says, "I feel full after eating a small meal." d. reports problems with dry mouth and constipation.
A
Which action should be included in all bladder-retraining programs? a. Toileting at bedtime c. Toileting every hour b. Using adult incontinence pads d. Providing 1000 ml of fluids daily
A
Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Assess for signs of impulsive eating. d. Explore needs for health teaching.
A
Which of the following is a true statement about elimination in older adults? a. Defecation less than once each day is not necessarily constipation. b. Mineral oil is recommended as a laxative for the older adult. c. Excessive sleep can be a symptom of constipation. d. Leaking liquid feces should be treated as diarrhea.
A
Which option is part of a program that addresses bowel incontinence in an older adult patient? a. Ensuring that a toilet or commode is readily accessible to the patient b. Encouraging the intake of 1 liter of water each day c. Expecting a rapid and full recovery d. Toileting the patient 10 to 15 minutes after meals
A
In some Middle Eastern and African cultures, female genital mutilation is a prerequisite for marriage. Women who now live in North America need care from nurses who are knowledgeable about the procedure and comfortable with the abnormal appearance of their genitalia. When caring for this client, the nurse can formulate a diagnosis with the understanding that the client may be at risk for which of the following? (Select all that apply.) a. Infection b. Laceration c. Hemorrhage d. Obstructed labor e. Increased signs of pain response
A,B,C,D
Continuous indwelling catheter use is indicated for which condition(s)? (Select all that apply.) a. Urethral obstruction c. Stress incontinence b. Urinary retention d. Severely impaired skin integrity
A,B,D
Long-term use of external catheters can lead to which complication(s)? (Select all that apply.) a. Fungal skin infections b. Penile skin maceration c. Atrophy d. Edema e. Phimosis
A,B,D,E
The nurse is assessing a client in her 37th week of pregnancy for the psychological responses commonly experienced as birth nears. Which psychological responses should the nurse expect to asses? (Select all that apply.) a. The client is excited to see her baby. b. The client has not started to prepare the nursery for the new baby. c. The client expresses concern about how to know if labor has started. d. The client and her spouse are concerned about getting to the birth center in time. e. The client and her spouse have not discussed how they will share household tasks.
A,C,D
A patient referred to the eating disorders clinic has lost 35 pounds in 3 months. For which physical manifestations of anorexia nervosa should a nurse assess? Select all that apply. a. Peripheral edema b. Parotid swelling c. Constipation d. Hypotension e. Dental caries f. Lanugo
A,C,D,F
A client who is 7 months pregnant states, "I'm worried that something will happen to my baby." Which is the nurse's best response? a. "Your baby is doing fine." b. "Tell me about your concerns." c. "There is nothing to worry about." d. "The doctor is taking good care of you and your baby."
B
A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data may be unreliable. b. Patient involvement in decision making increases sense of control and promotes compliance with treatment. c. Because of increased risk of physical problems with refeeding, the patient's permission is needed. d. A team approach to planning the diet ensures that physical and emotional needs will be met.
B
An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient: a. to eat a small meal after purging. b. not to skip meals or restrict food. c. to increase oral intake after 4 PM daily. d. the value of reading journal entries aloud to others.
B
An expectant client in her third trimester reports that she developed a strong tie to her baby from the beginning and now is really in tune to her baby's temperament. The nurse interprets this as the development of which maternal task of pregnancy? a. Learning to give of herself b. Developing attachment with the baby c. Securing acceptance of the baby by others d. Seeking safe passage for herself and her baby
B
The nurse assesses a male resident in a nursing home for urinary incontinence and determines that he is unaware of the problem. Which recommendation should the nurse implement? a. Limit oral fluid intake. c. Apply absorbent undergarment. b. Provide regular toileting. d. Encourage frequent rest periods.
B
The nurse is caring for a patient who has recently had an indwelling catheter placed. The nurse should assess the patient for: a. An increase in oral fluid intake c. Upper back pain b. A change in mental status d. A decrease in activity
B
The nurse wants to begin helping a resident who is overweight and has urinary incontinence with healthy bladder behavior skills. Which intervention should the nurse implement? a. Begin a low-calorie diet for weight management. b. Schedule voiding at 2- to 4-hour intervals. c. Instruct the resident to practice abdominal exercises. d. Reduce the time between an urge to void and voiding.
B
What is the term for the step in maternal role attainment that relates to the woman giving up certain aspects of her previous life? a. Fantasy b. Grief work c. Role-playing d. Looking for a fit
B
Which comment made by a new mother to her own mother is most likely to encourage the grandmother's participation in the infant's care? a. "Could you help me with the housework today?" b. "The baby is spitting up a lot. What should I do?" c. "I know you are busy, so I'll get John's mother to help me." d. "The baby has a stomachache. I'll call the nurse to find out what to do."
B
Which is a major concern among members of lower socioeconomic groups? a. Practicing preventive health care b. Meeting health needs as they occur c. Maintaining an optimistic view of life d. Maintaining group health insurance for their families
B
Which nursing intervention has the highest priority as a patient diagnosed with anorexia nervosa begins to gain weight? a. Assess for depression and anxiety. b. Observe for adverse effects of refeeding. c. Communicate empathy for the patient's feelings. d. Help the patient balance energy expenditures with caloric intake.
B
Which of the following would be considered to be a system barrier to the birth of prenatal care? a. Adolescent pregnant client b. Inability to schedule an appointment with the health care provider because of a busy medical practice c. Pregnant client has no health insurance d. Having to sign in for the initial appointment and complete health history records
B
Which personality characteristic is a nurse most likely to assess in a patient diagnosed with anorexia nervosa? a. Carefree flexibility c. Open displays of emotion b. Rigidity, perfectionism d. High spirits and optimism
B
A Vietnamese client who speaks little English is admitted to the labor and birth unit in early labor. The nurse plans to use an interpreter during an initial assessment. Which should the nurse plan to implement with regard to using an interpreter? (Select all that apply.) a. Face the interpreter when speaking. b. Listen carefully to what the client says. c. Speak slowly and smile when appropriate. d. Plan to use a male interpreter, even if a female interpreter is available. e. Ask the interpreter to explain exactly what is said as much as possible, instead of paraphrasing.
B,C,E
A 5-year-old child was diagnosed with encopresis. Which assessment finding would the nurse expect associated with this diagnosis? The child: a. frequently smears feces on clothing and toys. b. experiences frequent nocturnal episodes of bedwetting. c. has accidents of defecation at kindergarten three times a week. d. has occasional episodes of voiding accidents at the day care center.
C
A large residual urine volume characterizes what type of incontinence? a. Urge c. Overflow b. Stress d. Functional
C
A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of: a. maintaining patients' concentration and attention. b. shifting the patients' focus from food to psychotherapy. c. promoting processing of anxiety associated with eating. d. focusing on weight control mechanisms and food preparation.
C
A nurse provides health teaching for a patient diagnosed with binge-purge bulimia. Priority information the nurse should provide relates to: a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. how to recognize hypokalemia. d. self-esteem maintenance.
C
A patient referred to the eating disorders clinic has lost 35 pounds during the past 3 months. To assess eating patterns, the nurse should ask the patient: a. "Do you often feel fat?" b. "Who plans the family meals?" c. "What do you eat in a typical day?" d. "What do you think about your present weight?"
C
A pregnant client relates a story of how her boyfriend is feeling her aches and pains associated with her pregnancy. She is concerned that her boyfriend is making fun of her concerns. How would you respond to this client statement? a. Tell her not to worry because it is natural for her boyfriend to make her feel better by identifying with her pregnancy. b. Refer the client to a psychologist for counseling to deal with this problem because it is clearly upsetting her. c. Explain that her boyfriend may be experiencing couvade syndrome and that this is a normal finding seen with male partners. d. Ask the client specifically to define her concerns related to her relationship with her boyfriend and suggest methods to stop this type of behavior by her significant other.
C
An older woman tells the nurse practitioner that she fears her family will place her in a nursing home because she developed stress incontinence. Which recommendation should the nurse implement? a. Tell her to eliminate the use of caffeinated beverages. b. Coordinate a family conference with the older adult. c. Recommend exercises to strengthen the pelvic floor. d. Schedule voiding for every 2 hours around the clock.
C
As a patient admitted to the eating disorders unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet 4 inches tall. Which term should be documented? a. Amenorrhea c. Lanugo b. Alopecia d. Stupor
C
During the course of the pregnancy, the client states that she feels a deep connection with her unborn child. This behavior illustrates the maternal task acquisition of: a. safe passage. b. gaining acceptance. c. fostering an interconnection. d. developing empathy through physical actions.
C
Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating b. Bulimia nervosa c. Anorexia nervosa d. Eating disorder not otherwise specified
C
The nurse understands that stress incontinence occurs: a. With a urinary tract infection (UTI) b. Because of emotional strain c. As a result of increased intraabdominal pressure d. With a specific amount of urine in the bladder
C
Which situation best describes a man trying on fathering behaviors? a. Reading books on newborn care b. Spending more time with his siblings c. Coaching a little league baseball team d. Exhibiting physical symptoms related to pregnancy
C
The nurse evaluates the urinalysis (UA) of a female patient with an indwelling urinary catheter. The UA report shows gross contamination of the urine. Rank the nursing interventions in order, beginning with the first intervention the nurse should implement. A. Provide perineal hygiene. B. Provide urinary catheter care. C. Check the duration of catheterization. D. Obtain a urine specimen from a sterile port.
C B A D
A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? Select all that apply. a. Flexible mealtimes b. Unscheduled weight checks c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips f. Privileges correlated with emotional expression
C,D,E
A nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Which response by the nurse is appropriate? a. "You and I will have to sit down and discuss this problem." b. "It bothers me to see you exercising. I am afraid you will lose more weight." c. "Let's discuss the relationship between exercise, weight loss, and the effects on your body." d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."
D
A nursing diagnosis for a patient diagnosed with bulimia nervosa is Ineffective coping related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will: a. appropriately express angry feelings. b. verbalize two positive things about self. c. verbalize the importance of eating a balanced diet. d. identify two alternative methods of coping with loneliness.
D
A patient arrives to the clinic 2 hours late for her prenatal appointment. This is the third time she has been late. What is the nurse's best action in response to this patient's tardiness? a. Ask the patient if she has a way to tell the time. b. Ask the patient if she is deliberately being late for her appointments. c. Determine if the patient wants this baby and if this is her way of acting out. d. Determine if the patient arrives after the start time for other types of appointments.
D
A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair over the trunk. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient says, "I won't eat until I look thin." Select the priority initial nursing diagnosis. a. Anxiety related to fear of weight gain b. Disturbed body image related to weight loss c. Ineffective coping related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements related to self-starvation
D
A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 2.7 mg/dL. Which nursing diagnosis applies? a. Adult failure to thrive related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Ineffective health maintenance related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d. Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia
D
A pregnant client comes into the medical clinic stating that her family and friends are telling her that she is always talking about the pregnancy and nothing else. She is concerned that something is wrong with her. What psychological behavior is she exhibiting? a. Antepartum obsession b. Ambivalence c. Uncertainty d. Introversion
D
A psychiatric clinical nurse specialist uses cognitive-behavioral therapy for a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? a. "What are your feelings about not eating foods that you prepare?" b. "You seem to feel much better about yourself when you eat something." c. "It must be difficult to talk about private matters to someone you just met." d. "Being thin doesn't seem to solve your problems. You are thin now but still unhappy."
D
An expectant client asks the nurse about the behavior of "mimicry." Which is an example of mimicry that the nurse should relate to the client? a. Daydreaming about the newborn b. Imagining oneself as a good mother c. Babysitting for a neighbor's children d. Wearing maternity clothes before they are needed
D
An expectant couple asks the nurse about intercourse during pregnancy and whether it is safe for the baby. What should the nurse tell the couple? a. Intercourse is safe until the third trimester. b. Safer sex practices should be used once the membranes rupture. c. Intercourse should be avoided if any spotting from the vagina occurs afterward. d. Intercourse and orgasm are often contraindicated if a history of or signs of preterm labor are present.
D
Disturbed body image is a nursing diagnosis established for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat congruence with height, frame, age, and sex b. Calorie intake is within required parameters of treatment plan c. Weight reaches established normal range for the patient d. Patient expresses satisfaction with body appearance
D
Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will: a. weigh self accurately using balanced scales. b. limit exercise to less than 2 hours daily. c. select clothing that fits properly. d. gain 1 to 2 pounds.
D
The nurse in labor and birth is caring for a Muslim client during the active phase of labor. The nurse notes that the client quickly draws away when touched. Which intervention should the nurse implement? a. Ask the charge nurse to reassign you to another client. b. Assume that she doesn't like you and decrease your time with her. c. Continue to touch her as much as you need to while providing care. d. Limit touching to a minimum because physical contact may not be acceptable in her culture.
D
The nurse reveals to the patient that the over-the-counter test is verified and that she is pregnant. The patient confides to the nurse, "We have wanted to be pregnant for some time. These last few days I have been questioning our decision. I am feeling really bad right now." What is the nurse's best response? a. "You will come around in time and you will grow to love this baby." b. "Don't feel bad. It is the hormones of pregnancy talking right now." c. "Why do you think you are feeling bad when you wanted to be pregnant?" d. "Your feelings are understandable. Ambivalence is not uncommon right now."
D
The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention "monitor for complications of refeeding." Which system should a nurse closely monitor for dysfunction? a. Renal c. Integumentary b. Endocrine d. Cardiovascular
D
What is the most important aspect of care for the nurse to maintain when assisting an older patient with urinary incontinence? a. Availability of protective rubber garments b. Using indwelling urinary catheters c. Using smooth muscle relaxants d. Maintaining an attitude that is respectful and positive about resolving the problem
D
Which assessment finding for a patient diagnosed with an eating disorder meets criteria for hospitalization? a. Urine output 40 mL/hr c. Serum potassium 3.4 mEq/L b. Pulse rate 58 beats/min d. Systolic blood pressure 62 mm Hg
D
Which client may require more help and understanding when integrating the newborn into the family? a. A primipara from an upper income family b. A primipara who comes from a large family c. A multipara (gravida 2) who has a supportive husband and mother d. A multipara (gravida 6) who has two children younger than 3 years
D
Which comment made by a client in her first trimester indicates ambivalent feelings? a. "My body is changing so quickly." b. "I haven't felt well since this pregnancy began." c. "I'm concerned about the amount of weight I've gained." d. "I wanted to become pregnant, but I'm scared about being a mother."
D
Which comment made by a new mother exhibits understanding of her toddler's response to a new sibling? a. "I can't believe he is sucking his thumb again." b. "He is being difficult and I don't have time to deal with him." c. "When we brought the baby home, we made Michael stop sleeping in the crib." d. "My husband is going to stay with the baby so I can take Michael to the park tomorrow."
D
Which nursing diagnosis is more appropriate for a patient diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient diagnosed with bulimia nervosa who purges? a. Powerlessness b. Ineffective coping c. Disturbed body image d. Imbalanced nutrition: less than body requirements
D
While teaching an Asian client about prenatal care, the nurse notes that the client refuses to make eye contact. Which is the most likely cause? a. A submissive attitude b. Lack of understanding c. Embarrassment about the subject d. Cultural beliefs about eye contact
D
Which signs and symptoms are characteristic of a urinary tract infection (UTI) in an older adult? (Select all that apply.) a. Fever b. Uremia c. Dysuria d. Anorexia e. Flank pain f. Turbid urine
D,F
