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Questions 164

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Question 1 of 5

The nurse is reinforcing meal planning teaching to a group of clients with celiac disease. Which meal is appropriate for the nurse to include?

Correct Answer: C

Rationale: Grilled chicken, green beans, and mashed potatoes are gluten-free, suitable for celiac disease. Dinner rolls, breaded pork chops, and spaghetti contain gluten, which must be avoided.

Question 2 of 5

The nurse is caring for a client who is very demanding. She frequently rings the bell and asks to have her pillow fluffed or the water glass filled. Which response by the nurse will likely be most effective?

Correct Answer: D

Rationale: Acknowledging potential underlying concerns invites the client to express needs, reducing demands. Constant responses reinforce behavior, and dismissive or confrontational responses escalate tension.

Question 3 of 5

The nurse is reinforcing instructions to a postpartum client about cord care for the newborn. Which client statement indicates a need for further teaching?

Correct Answer: D

Rationale: Securing the diaper over the cord traps moisture, increasing infection risk. The cord turning black, falling off naturally, and sponge baths are correct cord care practices.

Question 4 of 5

The nurse is caring for a client who was admitted for treatment of schizoaffective disorder with visual hallucinations. He tells the nurse that he sees extraterrestrials that are coming to get him. What is the best nursing response?

Correct Answer: D

Rationale: Reflecting the client's statement validates his experience without reinforcing the hallucination, promoting therapeutic communication.

Question 5 of 5

Which incidence should be documented on an unusual incident report?

Correct Answer: D

Rationale: A fall is an unusual incident requiring documentation due to potential injury and liability. Leaving AMA, transfusion fever, or upset stomach are notable but less likely to require an incident report.

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