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Questions 149

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Question 1 of 5

A client in restraints is assigned to a newly graduated nurse. The nurse understands that which of the following are true regarding restraints? Select all that apply.

Correct Answer: A, C, F

Rationale: Restraints include chemical, mechanical, or physical methods; bed rails are restraints if used to restrict movement; and non-restraint alternatives like active listening are preferred. Pediatric time limits and reassessment frequency vary by policy, and reapplication requires new orders.

Question 2 of 5

A mother tells the nurse that her daughter has become quite a collector, filling her room with Beanie babies, dolls, and stuffed animals. The nurse recognizes that the child is developing:

Correct Answer: C

Rationale: Collecting items reflects concrete operational thinking, where children (ages 7-11) organize and categorize objects systematically, per Piaget's stages.

Question 3 of 5

The nurse is caring for an adolescent with a 5-year history of bulimia. A common clinical finding in the client with bulimia is:

Correct Answer: B

Rationale: Dental caries are common in bulimia due to frequent vomiting, which exposes teeth to stomach acid, causing enamel erosion.

Question 4 of 5

A client taking Dilantin (phenytoin) for tonic-clonic seizures is preparing for discharge. Which information should be included in the client's discharge care plan?

Correct Answer: C

Rationale: Phenytoin requires regular blood work to monitor levels and prevent toxicity, which can cause side effects like gingival hyperplasia.

Question 5 of 5

The nurse recognizes that if eaten by a client, which food can alter results when stool is checked for occult blood?

Correct Answer: D

Rationale: Beef contains heme, which can cause a false-positive result in a fecal occult blood test. Other foods listed do not typically interfere.

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