A nurse is collecting a health history from the guardian of a 4year old child. Which of the following statements by the guardian is the priority for the nurse to address?

I have a difficult time getting my child to eat green vegetables

My child continually asks me the same questions

My child still wets the bed at least two times per week

I have noticed that my child is withdrawn since we switched day care providers

Answer and Explanation

The Correct Answer is D

A) I have a difficult time getting my child to eat green vegetables: While it’s common for preschoolers to be selective about food, especially vegetables, this issue does not represent an immediate concern for the child’s health or development. This issue can often be addressed with strategies to encourage healthy eating, but it is not as urgent as other concerns.

B) My child continually asks me the same questions: Repetitive questioning is a normal part of preschool development, as children at this age are curious and often seek reassurance. It reflects their cognitive development as they try to understand the world around them. While it may be tiring for the guardian, it is not an immediate concern.

C) My child still wets the bed at least two times per week: Bedwetting (enuresis) is common among preschool-aged children, and many children do not gain full bladder control until after age 5. This issue is typically addressed if it continues past the age of 5, but it is not a priority at this time.

D) I have noticed that my child is withdrawn since we switched day care providers: This statement indicates a potential emotional or behavioral issue that requires immediate attention. Changes in behavior, such as withdrawal, can be a sign of stress, anxiety, or difficulty adjusting to a new environment. The nurse should prioritize this concern, as it may indicate that the child is having difficulty coping with the transition and may need additional support or evaluation. Addressing emotional well-being is a priority for the nurse.

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Correct Answer is A

Explanation

A) Bran muffin:
Bran is high in fiber, which is beneficial for managing constipation. Fiber helps to promote bowel movements by adding bulk to stool and improving gut motility. A bran muffin is an excellent choice for a client with constipation because it is rich in insoluble fiber, which is particularly effective in relieving constipation.

B) Tomato juice:
While tomato juice can provide some vitamins and nutrients, it is low in fiber, which is essential for managing constipation. For constipation relief, it is better to choose foods high in fiber, such as whole grains, fruits, and vegetables.

C) Puffed rice cereal:
Puffed rice cereal is low in fiber, making it an unsuitable choice for someone with constipation. Although it may provide some calories, it does not offer the beneficial fiber that can help relieve constipation.

D) Cottage cheese:
Cottage cheese is low in fiber and high in protein, but it does not contribute to bowel regularity. For constipation management, it is crucial to choose foods that are high in fiber, like fruits, vegetables, and whole grains, rather than low-fiber foods like cottage cheese.

A. Ensuring that creases in the stockings on the front of the client's legs B. Applying the stockings before the client gets out of bed C. Asking the client to point their toes before applying the stockings D. Turning the stockings inside out before applying them

Correct Answer is A

Explanation

A) Ensuring that creases in the stockings on the front of the client's legs:
This action requires intervention. The stockings should be applied smoothly and without any wrinkles or creases, as these can cause pressure points that may lead to skin irritation, impaired circulation, or discomfort for the client. The nurse should ensure that the assistive personnel applies the stockings correctly and without any creases to prevent these issues.

B) Applying the stockings before the client gets out of bed:
This is an appropriate action. Antiembolic stockings should be applied while the client is in a resting position, preferably before getting out of bed, to prevent venous stasis and improve circulation. Applying them while the client is lying down allows for proper fitting and ensures the stockings are worn during periods of immobility.

C) Asking the client to point their toes before applying the stockings:
This is an acceptable action. Asking the client to point their toes helps to stretch and align the legs for proper stocking application, making it easier to apply the stockings without causing discomfort. It is a good practice to ensure the stockings are applied properly while the client's feet and legs are positioned correctly.

D) Turning the stockings inside out before applying them:
This is a correct action. Turning the stockings inside out can help to prevent the stockings from rolling or bunching during application. It also allows the assistive personnel to place them on the client more easily and ensures a proper fit. The stockings should be turned right-side out after being applied to the legs.

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A nurse is collecting a health history from the guardian of a 4year old child. Which of the following statements by the guardian is the priority for the nurse to address?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is A

Explanation

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