A nurse is caring for a client who is obese. The client is crying and states, "Everyone is staring at me because of my weight." Which of the following responses should the nurse make?

"How long have you struggled with your weight?"

"Let's discuss some weight loss strategies that might work for you."

"It sounds like you're saying that you feel uncomfortable around others."

"Have you always felt uncomfortable being overweight?"

Answer and Explanation

The Correct Answer is C

A. "How long have you struggled with your weight?" While this may provide background information, it shifts the focus to the client's weight history rather than validating their current emotional experience and distress.
B. "Let's discuss some weight loss strategies that might work for you." This response prematurely shifts to problem-solving and weight management without first addressing the client’s emotional needs or acknowledging their feelings of embarrassment and vulnerability.
C. "It sounds like you're saying that you feel uncomfortable around others." This is a therapeutic, reflective response that validates the client’s feelings and encourages them to express more about their emotional experience, fostering trust and emotional support.
D. "Have you always felt uncomfortable being overweight?" This question may come across as judgmental and focuses too much on the client's body image history rather than their current emotional experience, potentially worsening feelings of shame.

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Correct Answer is A

Explanation

A. Measure the tubing from the nose to the distal port. Proper placement of an NG tube requires measuring from the tip of the nose to the earlobe, then to the xiphoid process. This ensures the tube reaches the stomach without curling or entering the airway.
B. Position the child at a 10 to 20 angle after feeding. A head elevation of at least 30 to 45 degrees is necessary during and after NG feedings to reduce the risk of aspiration. A 10 to 20 degree angle is too low and unsafe for post-feeding positioning.
C. Complete the feeding in 5 min. NG feedings should be given slowly over 20 to 30 minutes to prevent gastrointestinal discomfort, cramping, or vomiting. A 5-minute infusion is too rapid and may overwhelm the child’s digestive capacity.
D. Warm the formula in the microwave. Microwaving formula can lead to uneven heating and hot spots, which pose a burn risk to the child. Formula should be warmed by placing the container in warm water and testing the temperature before administration.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

Explanation

Panic disorder: Typically presents with intense fear, chest pain, shortness of breath, dizziness, and a sense of doom. It is episodic, not sustained like mania, and does not include symptoms like euphoria, grandiosity, or hallucinations.
Catatonia: Involves motor immobility, stupor, rigidity, or excessive purposeless movement. While this client is very active, their activity is goal-directed but disorganized, consistent with mania, not catatonia.
Mania: Characterized by euphoric or irritable mood, increased energy, racing thoughts, pressured speech, poor judgment, impulsivity, and decreased need for sleep. The client displays grandiosity, impulsive spending, hyperactivity, pressured speech, insomnia, and hallucinations, all pointing to mania.
Major depressive disorder: Involves symptoms like anhedonia, depressed mood, fatigue, and decreased energy. This is inconsistent with the client's overactivity and euphoric behavior.
Delirium: Usually presents with acute confusion, fluctuating consciousness, and disorientation, often due to a medical condition or substance use. This client is consistently manic and does not show signs of fluctuating alertness or disorientation to time and person.
Anhedonia: Inability to feel pleasure, commonly seen in depression, not in mania.
Alogia: Poverty of speech or reduced speech output, often associated with schizophrenia, not consistent with this client’s pressured and loud speech.
Magical thinking: Believing that one's thoughts can influence reality, often seen in schizotypal personality disorder, not prominent here.
Euphoric mood: A classic symptom of mania, where the individual may feel overly joyful, energetic, and invincible, as reflected in the client's excessive confidence, impulsivity, and erratic behavior.
Hypervigilance: Commonly linked with anxiety disorders or PTSD, and not the most fitting descriptor for this client’s presentation.

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A nurse is caring for a client who is obese. The client is crying and states, "Everyone is staring at me because of my weight." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a nasogastric (NG) tube feeding to a school-age child. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

The nurse continues to care for the client. Exhibits Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is most likely experiencing dropdownas evidenced by the client'sdropdown

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

Explanation

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