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Questions 164

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Extract:


Question 1 of 5

A client on the psychiatric unit does not get to the dining room to eat because she is continually washing her hands and doesn't finish until after lunch. What should be included in the nursing care plan?

Correct Answer: B

Rationale: Advance notice allows the client with OCD to complete rituals before lunch, facilitating nutrition without confrontation.

Choices, discussions, or bans are less effective.

Question 2 of 5

The nurse is talking with the parent of a pediatric client with attention deficit hyperactivity disorder who has a new prescription for methylphenidate. The parent asks, 'How will I know that the medication is effective?' Which of the following responses would be appropriate for the nurse to make?

Correct Answer: D

Rationale: Methylphenidate improves focus and task completion in ADHD. It may increase irritability or decrease appetite as side effects, and sleep patterns vary but aren't a primary indicator of effectiveness.

Question 3 of 5

The charge nurse is observing the nurse apply a condom catheter for a client who is uncircumcised. The charge nurse should intervene if the nurse

Correct Answer: B

Rationale: Retracting the foreskin before applying a condom catheter risks paraphimosis if not repositioned afterward, requiring intervention. Other actions are correct: attaching tubing, assessing skin, and leaving space prevent complications.

Question 4 of 5

A 6-month-old infant is being seen in the doctor's office. Which observation by the nurse should be brought to the physician's attention?

Correct Answer: B

Rationale: A 6-month-old should double birth weight (14 lb expected for 7 lb); 10 lb suggests poor growth, requiring evaluation. Other findings are developmentally normal.

Question 5 of 5

A mother asks the nurse if she should be concerned about her child's tendency to stutter. What assessment data will be most useful in counseling the parent?

Correct Answer: A

Rationale: Age of the child. Stuttering is often a normal part of language development in preschoolers, making age a critical factor.

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