A nurse is assisting with the admission of a client who has limited mobility. Which of the following actions is the nurse's priority?

Demonstrate to the client how to use the signaling device.

Explain the facility's meal schedule

Demonstrate to the client how to use the television.

Explain the medication administration schedule.

Answer and Explanation

The Correct Answer is A

A. Demonstrate to the client how to use the signaling device: Teaching the client how to use the call light is the priority because it ensures they can easily ask for assistance, especially with limited mobility. Immediate access to help reduces the risk of falls, injury, and delays in meeting urgent needs.

B. Explain the facility's meal schedule: While it is important for the client to know when meals are served, this information does not impact their immediate safety or ability to get assistance when needed, making it a lower priority than teaching about the call light.

C. Demonstrate to the client how to use the television: Teaching about the television promotes comfort but is nonessential for safety or urgent needs. Comfort measures can be addressed after critical safety interventions have been completed.

D. Explain the medication administration schedule: Understanding medication schedules is important for client education and adherence, but ensuring the ability to call for help is more immediately critical, especially in a client with limited mobility.

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Correct Answer is A

Explanation

A. Monitor the client for 1 hr after meals: Clients with anorexia nervosa are at high risk for purging behaviors such as vomiting or excessive exercise after meals. Monitoring them for at least 1 hour post-meal helps prevent these behaviors and supports the therapeutic goal of safe weight restoration.

B. Allow the client 2 hr to finish meals: Allowing 2 hours to complete meals is too long and may encourage food avoidance behaviors. Structured meal times with limits (usually around 30 to 45 minutes) are important to establish routine eating habits and prevent manipulation of eating times.

C. Weigh the client every 2 days: Clients with anorexia nervosa are typically weighed daily, often at the same time each morning, to closely monitor weight trends and assess the effectiveness of the treatment plan. Monitoring every 2 days may miss rapid changes that require immediate intervention.

D. Check the client's vital signs two times per week: Vital signs should be checked daily in clients with anorexia nervosa, especially early in treatment, because of the risks of bradycardia, hypotension, and hypothermia. Infrequent monitoring can delay recognition of life-threatening physiological instability.

A. The infant was born large for gestational age. B. The infant has otitis media C. The infant is younger than 1 year of age. D. The infant's guardians are both over the age of 30.

Correct Answer is C

Explanation

A. The infant was born large for gestational age: Being large for gestational age is not recognized as a risk factor for child maltreatment. Risk factors are more often related to family dynamics, age, and social stressors rather than birth weight alone.

B. The infant has otitis media: Otitis media, or a middle ear infection, is a common pediatric illness and is not itself a risk factor for maltreatment. It reflects normal childhood health issues rather than abuse or neglect.

C. The infant is younger than 1 year of age: Infants under 1 year are particularly vulnerable to maltreatment because of their total dependence on caregivers and inability to communicate effectively. This age group is at the highest risk for serious injury from abuse.

D. The infant's guardians are both over the age of 30: Parental age over 30 does not inherently increase the risk for child maltreatment. Other factors like substance abuse, history of being abused, and high stress levels are more closely linked to maltreatment risk.

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A nurse is assisting with the admission of a client who has limited mobility. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

A nurse is contributing to the development of an in-service training about child maltreatment for a group of pediatric nurses. Which of the following findings should the nurse identify as a risk factor for child maltreatment?

Correct Answer is C

Explanation

The nurse is continuing to assist with the care of the client. For each finding, click to specify if the finding indicates that the client's condition has improved or has not changed.

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