Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting with planning care for a newly admited client who has anorexia nervosa. Which of the following interventions should the nurse recommend to include in the plan of care?
A. Encourage the client to gain 2.3 kg (5 lb) per week.
A weight gain goal of 0.5 to 1 kg (1 to 2 lb) per week is considered safe and realistic. Gaining 2.3 kg (5 lb) weekly is too aggressive and may cause physical and psychological stress for the client.
B. Monitor the client for 15 min after meals
Clients with anorexia nervosa are at risk for purging behaviors. Monitoring for only 15 minutes is insufficient. A 60-minute post-meal observation period is more appropriate to deter vomiting or excessive exercise.
C. Weigh the client each morning after voiding
Daily weights, taken at the same time each morning after voiding and before eating, provide consistent and accurate data to monitor progress and detect manipulation or fluid shifts.
D. Reinforce teaching about healthy eating during meals
Reinforcing education during meals can increase the client’s anxiety and resistance to eating. Teaching is best done separately from mealtimes to avoid associating eating with stress.
This question is an excerpt from Nurse Dive's nursing test bank - VATI PN Comprehensive Predictor 2020 Proctored Exam. Take the full exam now
Full Explanation
Answer: C. Weigh the client each morning after voiding
Rationale:
A. Encourage the client to gain 2.3 kg (5 lb) per week:
A weight gain goal of 0.5 to 1 kg (1 to 2 lb) per week is considered safe and realistic. Gaining 2.3 kg (5 lb) weekly is too aggressive and may cause physical and psychological stress for the client.
B. Monitor the client for 15 min after meals:
Clients with anorexia nervosa are at risk for purging behaviors. Monitoring for only 15 minutes is insufficient. A 60-minute post-meal observation period is more appropriate to deter vomiting or excessive exercise.
C. Weigh the client each morning after voiding:
Daily weights, taken at the same time each morning after voiding and before eating, provide consistent and accurate data to monitor progress and detect manipulation or fluid shifts.
D. Reinforce teaching about healthy eating during meals:
Reinforcing education during meals can increase the client’s anxiety and resistance to eating. Teaching is best done separately from mealtimes to avoid associating eating with stress.
Similar Questions
A nurse is collecting data from the guardian of a toddler during a well-child visit. The guardian expresses concern to the nurse because his child has a poor appetite, but drinks a quart of milk each day.
The nurse should identify that this practice places the toddler at risk for which of the following conditions?
A. Celiac disease
Celiac disease is an autoimmune disorder triggered by the ingestion of gluten-containing foods, not specifically related to milk consumption.
B. Lactose intolerance
Lactose intolerance is a condition where the body has difficulty digesting lactose, the sugar found in milk, but it does not necessarily relate to the amount of milk consumed.
C. Acute renal failure
Acute renal failure is a severe condition involving the sudden loss of kidney function and is not directly associated with milk consumption.
D. Iron-deficiency anemia
Excessive milk consumption in toddlers can put them at risk for iron-deficiency anemia. Milk is a poor source of iron, and when a child consumes a large amount of milk, it can displace other iron-rich foods from their diet. Iron is essential for the production of hemoglobin, which carries oxygen in the blood. When a child does not consume enough iron, it can lead to iron-deficiency anemia, which can result in symptoms such as fatigue, pale skin, weakness, and poor appetite.
A nurse is caring for a client who is receiving IV fluids. The nurse realizes that the incorrect IV solution is infusing. Which of the following actions should the nurse take?
A. Complete an incident report
completing an incident report, may be necessary after the immediate situation has been addressed, but it should not be the nurse's first action. The priority is to stop the incorrect solution from infusing.
B. Allow the current solution to finish infusing, then change the bag
allowing the current solution to finish infusing and then changing the bag, is not the correct action. Continuing the infusion of the incorrect solution can potentially harm the client and must be stopped immediately.
C. Document that an error occurred in the client's medical record.
documenting that an error occurred in the client's medical record, is important, but it should be done after taking immediate action to stop the incorrect solution from infusing. Documentation should include the details of the incident, any actions taken, and the client's response.
D. Remove the IV catheter.
Full Explanation
d. Remove the IV catheter.
Explanation:
The correct answer is d. Remove the IV catheter.
If the nurse realizes that the incorrect IV solution is infusing, it is essential to take prompt action to prevent harm to the client. Removing the IV catheter is the appropriate course of action to stop the infusion of the incorrect solution.
Option a, completing an incident report, may be necessary after the immediate situation has been addressed, but it should not be the nurse's first action. The priority is to stop the incorrect solution from infusing.
Option b, allowing the current solution to finish infusing and then changing the bag, is not the correct action. Continuing the infusion of the incorrect solution can potentially harm the client and must be stopped immediately.
Option c, documenting that an error occurred in the client's medical record, is important, but it should be done after taking immediate action to stop the incorrect solution from infusing. Documentation should include the details of the incident, any actions taken, and the client's response.
By promptly removing the IV catheter, the nurse stops the infusion of the incorrect solution and prevents further harm to the client. Afterward, the nurse should assess the client for any adverse effects, inform the appropriate healthcare providers, and follow the facility's policies and procedures for reporting incidents and documenting the error.
A nurse is reinforcing teaching about self-administration of nasal drops with a client. Which of the following positions should the nurse recommend for instillation of the drops?
A. Sims
Simsposition is a side-lying position with the upper leg flexed. This position is often used for rectal examinations or procedures and is not suitable for instilling nasal drops.
B. Prone
Prone position refers to lying face down. It is not ideal for administering nasal drops as it can obstruct proper access to the nostrils and make it difficult to instill the drops accurately.
C. Supine
When instructing a client on self-administration of nasal drops, the nurse should recommend the supine position. In the supine position, the client lies on their back with the head slightly elevated. This position allows for easy access to the nostrils and facilitates the proper instillation of the nasal drops.
D. Orthopneic
Orthopneic position is a sitting position with the upper body supported by pillows. It is commonly used by individuals with respiratory distress to facilitate breathing. However, it is not specifically recommended for administering nasal drops as it may not provide optimal access to the nostrils for proper instillation.
Full Explanation
When instructing a client on self-administration of nasal drops, the nurse should recommend the supine position. In the supine position, the client lies on their back with the head slightly elevated. This position allows for easy access to the nostrils and facilitates the proper instillation of the nasal drops.
The other options are not recommended for instillation of nasal drops for various reasons:
a) Sims position: Sims position is a side-lying position with the upper leg flexed. This position is often used for rectal examinations or procedures and is not suitable for instilling nasal drops.
b) Prone position: Prone position refers to lying face down. It is not ideal for administering nasal drops as it
can obstruct proper access to the nostrils and make it difficult to instill the drops accurately.
d) Orthopneic position: Orthopneic position is a sitting position with the upper body supported by pillows. It is commonly used by individuals with respiratory distress to facilitate breathing. However, it is not specifically recommended for administering nasal drops as it may not provide optimal access to the nostrils for proper instillation.
