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Questions 158

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Extract:


Question 1 of 5

A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be:

Correct Answer: B

Rationale: This outcome criterion is inadequate because the term 'accepts' is not directly measurable. This outcome criterion is directly measurable because specific goal-related verbalizations can be heard and verified by the nurse. 'Improved perception of body image' is not directly measurable and is therefore open to many interpretations. Although long-term goals for the anorexic client should focus on increased self-esteem, this outcome criterion (as stated) does not include specific indicators or behaviors for which to observe.

Question 2 of 5

The client is diagnosed with hyperkalemia. Which food should the nurse instruct the client to avoid?

Correct Answer: A

Rationale: Bananas are high in potassium, which should be avoided in hyperkalemia to prevent worsening arrhythmias. Broccoli, salmon, and pasta have lower potassium content.

Question 3 of 5

Home-care instructions for the child following a cardiac catheterization should include:

Correct Answer: B

Rationale: A small bruise may develop around the insertion site and is not a reason for alarm. It is best to keep the child out of the bathtub until the sutures are removed. Acetaminophen, not aspirin, is the drug of choice if there is pain at the insertion site. The insertion site should be kept clean and dry and open to air.

Question 4 of 5

A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be:

Correct Answer: B

Rationale: This outcome criterion is inadequate because the term 'accepts' is not directly measurable. This outcome criterion is directly measurable because specific goal-related verbalizations can be heard and verified by the nurse. 'Improved perception of body image' is not directly measurable and is therefore open to many interpretations. Although long-term goals for the anorexic client should focus on increased self-esteem, this outcome criterion (as stated) does not include specific indicators or behaviors for which to observe.

Question 5 of 5

A client with a history of tuberculosis is admitted with complaints of hemoptysis. The nurse should give priority to:"

Correct Answer: B

Rationale: Hemoptysis in tuberculosis indicates potential lung tissue damage, so monitoring respiratory status is critical to assess for airway compromise or worsening infection.

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