A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?

Ecchymotic blood accumulations.

Evidence of patches of lost hair.

Episodic complaints of pruritus.

Erythema of the localized lesions.

Answer and Explanation

The Correct Answer is A

Choice A Rationale:
Ecchymotic blood accumulations (bruises) are indicative of possible trauma or injury to the scalp. In this case, it suggests that the hair loss is likely due to physical manipulation (such as pulling or arranging the hair to cover bald spots) rather than a medical condition.

Choice B rationale:
This choice suggests that evidence of patches of lost hair would be indicative of non-disease-related hair loss. However, this is not necessarily true. Medical conditions, such as alopecia areata, can also cause patchy hair loss without physical trauma. Therefore, it is not a definitive indicator that hair loss is not disease-related.

Choice C rationale:
Episodic complaints of pruritus (itching) could be associated with various scalp conditions, including those that lead to hair loss. Itching alone does not rule out disease-related hair loss. In fact, some medical conditions can cause both itching and hair loss.

Choice D rationale:
Erythema (redness) of localized lesions may suggest inflammation but does not necessarily indicate non-disease-related hair loss. Medical conditions can also cause localized inflammation and hair loss.

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Correct Answer is B

Explanation

Choice A rationale:
Sweet potatoes are not typically high in oxalates and are generally considered safe to consume in moderation for individuals with calcium oxalate renal stones.

Choice B rationale:
Spinach is high in oxalates, which can contribute to the formation of calcium oxalate renal stones. Therefore, the client should be instructed to avoid spinach and foods high in oxalates.

Choice C rationale:
Bananas are generally low in oxalates and are not likely to be a significant contributor to the formation of calcium oxalate renal stones. They are safe for most individuals to consume.

Choice D rationale:
Fish is generally not high in oxalates and is not a major concern for individuals with calcium oxalate renal stones. However, it's essential to maintain an overall balanced diet and stay hydrated to prevent stone formation.

A. Explore changes in life that have occurred after the loss. B. Suggest the need for a psychiatric consultation. C. Offer a referral to pastoral counseling. D. Encourage attending a local support group.

Correct Answer is A

Explanation

Choice A rationale:
Exploring changes in life that have occurred after the loss is the first action the nurse should take. This allows the nurse to assess the client's grief, identify specific stressors, and understand how the loss is impacting the client's daily life and emotional well-being. It provides valuable information for tailoring further interventions and support.

Choice B rationale:
Suggesting the need for a psychiatric consultation may be premature as the nurse should first assess the client's grief and coping mechanisms. Referral for psychiatric consultation should be considered if the client's emotional distress is severe, persistent, or significantly impacting their functioning.

Choice C rationale:
Offering a referral to pastoral counseling may be appropriate for some clients, but it should not be the first action. The nurse should assess the client's needs and preferences before making such a referral.

Choice D rationale:
Encouraging attendance at a local support group can be beneficial, but it should not be the initial step. The nurse should first assess the client's current emotional state and needs to determine the most appropriate interventions.

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A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?

Correct Answer is B

Explanation

The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?

Correct Answer is A

Explanation

A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?

A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)

Which intervention(s) should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

Patient Data Exhibits here The nurse is reviewing the physician's orders. Which of the following physician's orders requires priority attention from the nurse? Select all that apply.

A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?