Safe and Effective Care Environment Nclex PN Questions - Nurselytic

Correct Answer: C

Rationale: The correct answer is 'The client verbalizes her body size accurately.' For clients with anorexia nervosa, body image disturbance is a common issue where they perceive themselves inaccurately. Verbalizing her body size accurately indicates progress towards correcting this distorted self-perception.

Choices A, B, and D are incorrect because they do not directly address the distorted body image perception seen in clients with anorexia nervosa.
Choice A focuses on knowledge of a maintenance diet, which is unrelated to body image perception.
Choice B involves assertiveness with family, which is more related to family dynamics.
Choice D addresses control of obsessive behaviors, which is not directly related to correcting the distorted body image perception.

Correct Answer: A

Rationale: The appropriate action for the nurse to take is to inform the client that ear pain may occur and is normal after a tonsillectomy. Referred pain in the ear is common due to related nerve pathways. It is essential to educate the client about this to alleviate concerns. Providing ice water and a straw is not recommended as they may irritate the throat and disturb the healing process. Hot beverages like tea should also be avoided for the same reason. While monitoring vitals every 15 minutes is crucial in the immediate postoperative period for early identification of any complications, it is not the most appropriate action in this scenario where addressing the client's concerns and providing education is key.

Correct Answer: A

Rationale: Variable decelerations can indicate cord compression as they are caused by umbilical cord compression or prolapse. This pattern shows an abrupt decrease in heart rate with an erratic shape, often resembling a V or W. Early decelerations (choice
B) are typically caused by head compression during contractions and are considered benign. Bradycardia (choice
C) is a consistent low heart rate below 110 bpm and is not specific to cord compression. Tachycardia (choice
D) is an abnormally high heart rate above 160 bpm and is not associated with cord compression.

Correct Answer: D

Rationale: When caring for a comatose client, it is crucial to monitor and maintain the integrity of the indwelling urinary catheter to prevent urinary tract infections and other complications. Changing the urinary catheter less frequently than recommended increases the risk of infection. In this scenario, the most concerning issue is the prolonged duration since the last change of the indwelling urinary catheter, which poses an immediate risk to the client's health. While repositioning every 2 hours is essential to prevent skin breakdown, the most critical aspect in this case is the catheter care. Bathing and skin assessment are important for overall hygiene and skin integrity but are not as urgent as catheter care. The timing of the PEG tube change, while relevant for care planning, is not as immediate a concern as the indwelling urinary catheter status.

Correct Answer: D

Rationale: When recovering from general anesthesia, hypoactive bowel sounds can be expected due to the effects of the anesthesia on gut motility. For the other clients, hearing less than 5 bowel sounds per minute would indicate an abnormal finding. In the context of the given situation, the client recovering from knee replacement surgery aligns with the expected range of bowel sounds post-general anesthesia.
Therefore, choice D is the correct answer.

Choices A, B, and C present scenarios where hearing less than 5 bowel sounds per minute would be abnormal, indicating potential issues that need further evaluation.