Nursing Elites

1. A nurse is reinforcing teaching about food choice with the mother of an 8-month-old infant. Which of the following statements by the mother indicates a need for further teaching?

• A. I will give my child peanut butter and mashed egg whites.
• B. I will give my child rice cereal and crackers.
• C. I will give my child pureed liver and strained pears.
• D. I will give my child applesauce and green peas.

Correct answer: A

Rationale: The correct answer is A because peanut butter and egg whites are not recommended for infants under 12 months due to the risk of choking and allergies. Choices B, C, and D are appropriate food choices for an 8-month-old infant. Rice cereal, crackers, pureed liver, strained pears, applesauce, and green peas are all suitable options for introducing solid foods to infants.

2. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor?

• A. FHT 168 beats/min
• B. Temperature 100 degrees Fahrenheit
• C. Cervical dilation of 4 cm
• D. BP 138/88

Correct answer: A

Rationale: The correct answer is A. Fetal heart rate elevation can indicate distress, making it an early sign of labor complications. Choices B, C, and D are not the best answers in this scenario. Choice B, an elevated temperature, could indicate infection but is not a direct sign of labor complications. Choice C, cervical dilation of 4 cm, is a normal part of labor progression for a primigravida. Choice D, a blood pressure of 138/88, falls within normal limits and is not an early indication of labor complications.

3. A client is receiving treatment for hypertension. Which of these findings would be most concerning to the nurse?

• A. A heart rate of 90 beats per minute
• B. A blood pressure of 120/80 mm Hg
• C. A respiratory rate of 16 breaths per minute
• D. A temperature of 98.6 degrees Fahrenheit

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 16 breaths per minute is within normal limits; however, changes in breathing patterns can indicate respiratory distress, which is concerning, especially in a client receiving treatment for hypertension. A heart rate of 90 beats per minute may not be alarming if the client is at rest. A blood pressure of 120/80 mm Hg is within the normal range for a healthy adult. A temperature of 98.6 degrees Fahrenheit is also considered normal, showing no immediate cause for concern in this scenario.

4. A healthcare professional is assisting with the development of an education program about nutritional risk among adolescents to a group of parents of adolescents. Which of the following information should the healthcare professional include in the teaching? (Select all that apply).

• A. Skipping more than three meals per week
• B. Eating fast food once a week
• C. Hearty appetite
• D. Drink whole milk to ensure adequate calcium intake.

Correct answer: A

Rationale: Skipping more than three meals per week is an indicator of poor nutritional habits in adolescents. This can lead to inadequate nutrient intake and negatively impact growth and development. Choices B, C, and D are not directly associated with poor nutritional habits among adolescents. Eating fast food once a week may not necessarily indicate poor nutrition if the overall diet is balanced. Having a hearty appetite does not provide specific information about nutritional risk, as appetite can vary among individuals. While whole milk can be a source of calcium, it is not necessary to drink whole milk specifically to ensure adequate calcium intake, as there are other sources of calcium available.

5. A client is receiving teaching about a high-fiber diet to manage constipation. Which statement indicates the best choice for a high-fiber diet?

• A. Eating one medium apple is a good snack option.
• B. Selecting a ½ cup of sweet potatoes for starch is a great choice.
• C. Choosing a ½ cup of bran cereal for breakfast is ideal.
• D. Opting for 1 ounce of almonds when hungry midday is recommended.

Correct answer: C

Rationale: The correct answer is C because bran cereal is a high-fiber food that can effectively alleviate constipation by promoting regular bowel movements. Option A, an apple, while a healthy snack, may not provide as much fiber as bran cereal. Option B, sweet potatoes, are nutritious but may not be as high in fiber as bran cereal. Option D, almonds, are a good source of healthy fats and protein but do not provide as much fiber as bran cereal.

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