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Question 1 of 5

A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy:

Correct Answer: A

Rationale: Anorexia nervosa clients feel out of control. Providing a structured environment offers safety and comfort and can help them to develop internal control, thus reducing their need to control by self-starvation. Distraction does not focus on the client's need for control. Doing frequent room checks reinforces feelings of powerlessness and the need to continue with the dysfunctional behavior. Participating in long discussions about food does not make the client want to eat, but rather this strategy allows her to indulge in her preoccupation and to continue with the dysfunctional behavior.

Question 2 of 5

A client arrives in the emergency room with severe burns of the hands, right arm, face, and neck. The nurse needs to start an IV.

Correct Answer: B

Rationale: The left antecubital fossa is suitable for IV placement, avoiding burned areas (right hand, arm, face, neck). The foot (
C) is less ideal due to infection risk, and the left forearm (
D) may be too close to burn sites.

Question 3 of 5

A client with a history of chronic renal failure is receiving hemodialysis. Which assessment finding indicates a complication during dialysis?

Correct Answer: B

Rationale: Hypotension during dialysis suggests fluid removal too rapid or disequilibrium syndrome, a serious complication. Fatigue (
A), headache (
C), and stable weight (
D) are less concerning.

Question 4 of 5

Which of the following describes the language development of a two-year-old?

Correct Answer: C

Rationale: A two-year-old typically can combine three or four words to form simple sentences (e.g., 'Me want milk'). They understand basic concepts like 'yes' and 'no,' but not all words. Repeatedly asking 'why?' is more common in older preschoolers.

Question 5 of 5

A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best auscultated just:

Correct Answer: A

Rationale: In LOA, the fetus's back is on the mother's left anterior side, so fetal heart sounds are best heard below the umbilicus on the left.

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