NCLEX Question of The Day - Nurselytic

Correct Answer: D

Rationale: The correct answer is to monitor food intake and behavior for one hour after meals. This is crucial in caring for a client with an eating disorder as it helps in assessing any immediate risks related to the disorder. Option A is incorrect as it may trigger additional stress for the client and distract from the main focus of managing the disorder. Option B, weighing the client daily, could lead to an unhealthy focus on weight and potentially worsen the client's mental health. Option C, restricting access to mirrors, although it may be beneficial for body image concerns, does not directly address the core issue of monitoring food intake and behavior, which is essential in managing eating disorders.

Correct Answer: C

Rationale: Prior to an EEG, it is essential for the client to eat to prevent a drop in blood sugar levels. The nurse should hold sedatives but allow the client to have breakfast and administer other necessary medications. Holding sedatives is crucial to ensure accurate EEG results, while providing breakfast helps maintain stable blood sugar levels. Administering other medications, excluding sedatives, is important for the client's overall care.

Choices A, C, and D are incorrect because keeping the client NPO and holding medications, administering medications but holding anticonvulsants, and giving additional fluids and caffeine are not appropriate actions before an EEG.

Correct Answer: C

Rationale: In a tension pneumothorax, the trachea deviates to the unaffected side due to increased pressure in the affected pleural space, causing respiratory distress. Dyspnea is a hallmark symptom as the lung on the affected side collapses, leading to difficulty in breathing. Sudden hypertension and bradycardia (
Choice
A) are not typical findings of tension pneumothorax. Productive cough with yellow mucus (
Choice
B) is more suggestive of respiratory infections rather than a tension pneumothorax. Sudden development of profuse hemoptysis and weakness (
Choice
D) is not characteristic of tension pneumothorax presentation.

Correct Answer: A

Rationale: The correct answer is to watch for changes in emotion and behavior. The frontal lobe, particularly the left side, is responsible for regulating behavior and emotions.
Therefore, following a left frontal lobe CVA, monitoring for alterations in emotion and behavior is crucial.

Choices B, C, and D are incorrect because loss of hearing, appetite and vision deficits, and changes in facial muscle control are not directly associated with a left frontal lobe CVA.

Correct Answer: A

Rationale: Lower extremity edema can indicate an overdose of Premarin. Premarin, an estrogen hormone replacement therapy, can cause fluid retention leading to edema in the lower extremities. Sensory changes in the upper extremities, increased occurrence of fractures, and decreased peripheral blood flow are not typically associated with an overdose of Premarin.