For correct answer choice:

The statement "My child only eats fruits and won't touch vegetables" is correct. This indicates a limited diet that lacks essential nutrients found in vegetables. The nurse should educate the parent on the importance of a well-rounded diet that includes both fruits and vegetables for optimal growth and development.

For incorrect answer choices:

The statement "I offer my child whole grains at every meal" is incorrect. Whole grains are an essential part of a balanced diet and contribute to dietary fiber, which is important for digestive health.

The statement "I make sure my child has a variety of foods throughout the week" is incorrect. Providing a variety of foods is important for ensuring that children receive a wide range of nutrients necessary for healthy growth.

The statement "I give my child low-fat dairy products daily" is incorrect. Daily consumption of low-fat dairy products supports calcium intake, which is crucial for bone health in growing children.

For the correct answer choice:
"Void immediately after sexual intercourse to flush out bacteria" is correct. Voiding after sexual activity helps to flush out any bacteria that may have entered the urethra, reducing the risk of UTIs.

For incorrect answer choices:
"Use hot water and soap to clean the genital area before and after voiding" is incorrect. Harsh cleansing practices can irritate the genital area. It is best to use warm water and mild soap, if necessary, without over-cleaning.
"Take a daily bath instead of a shower for thorough cleaning" is incorrect. Baths, especially those with added substances like bubble baths, can increase the risk of irritation and infection. Showers are generally recommended for clients with a history of UTIs.
"Avoid drinking caffeine to minimize bladder irritation" is incorrect. While reducing caffeine may help alleviate bladder irritation symptoms, it does not directly prevent UTIs. Adequate hydration is more important for UTI prevention.

For correct answer choice:

Assess the child's airway and breathing is correct. Ingesting bleach can cause chemical burns and respiratory distress. Therefore, evaluating the airway and respiratory status is critical to ensure the child is safe and stable.

For incorrect answer choices:

Flushing the child's mouth with water is incorrect. Rinsing the mouth can reduce irritation but the priority is to assess the airway and breathe first to ensure the child is not in immediate danger.

Asking the caregiver about the amount ingested is incorrect. Understanding the amount ingested is important for treatment planning but it is not the priority here. It should come after ensuring the child’s airway and breathing are stable.

Preparing to administer an antidote is incorrect. There is no specific antidote for bleach ingestion; therefore, the immediate focus should be on assessing the child's airway and breathing before considering further interventions.

For correct answer choice:

Identifying potential health issues early for timely intervention is correct. Routine health screenings help in the early detection of conditions such as obesity, vision problems, or hearing impairments, allowing for prompt management and support.

For incorrect answer choices:

Ensuring that children receive all recommended vaccinations is incorrect. While vaccinations are vital, the primary purpose of routine health screenings extends beyond immunizations to include overall health assessments.

Documenting children's growth and development for school records is incorrect. Although documentation is important, the primary goal of screenings is to assess health status and identify any issues rather than merely record growth data.

Meeting school district requirements for health assessments is incorrect. While compliance with school policies is necessary, the main focus of screenings is the health and well-being of the child, not just meeting administrative requirements.

For correct answer choice:

Administering oxygen is the best immediate action because increased restlessness and weakness, especially in the context of a TBI, may indicate worsening cerebral hypoxia. Supplemental oxygen can help improve the patient's oxygenation status and prevent further complications.

For incorrect answer choices:

Measuring the patient's blood pressure is incorrect. While monitoring blood pressure is important in TBI patients, it is not the most immediate action needed to address the patient's current symptoms of restlessness and weakness, which may indicate a decrease in cerebral perfusion.

Elevating the head of the bed to 30 degrees is incorrect. This can help with venous return and decrease intracranial pressure, but does not address the immediate need for oxygenation, which is critical in this scenario.

Increasing the IV rate and calling the physician is incorrect. This may be necessary eventually, but the immediate priority is to ensure adequate oxygenation for the patient, given the signs of distress.

For the correct answer choice:
A. Vesicular lesions at different stages of development are correct. In varicella (chickenpox), lesions often appear in various stages, such as macules, papules, vesicles, and crusts, indicating different stages of healing.

For incorrect answer choices:
A petechial rash localized to the lower extremities is incorrect. This could suggest a condition like meningococcemia or other bleeding disorders but not varicella.
Large, purplish nodules clustered on the face and trunk are incorrect. This description is not consistent with varicella and may suggest a different condition like Kaposi sarcoma.
Raised, scaly patches that are sharply demarcated are incorrect. This finding is more characteristic of psoriasis rather than varicella.

For correct answer choice:

Evaluating the patient for allergies to iodine or shellfish is correct. Since iodine-based contrast is commonly used during cardiac catheterization, determining any potential allergies is critical to prevent adverse reactions.

For incorrect answer choices:

Measuring the patient's blood pressure and heart rate is incorrect. Although vital signs are essential to monitor, they are not as critical as identifying allergies before administering contrast media.

Assessing the patient's dietary intake is incorrect. While dietary restrictions may be relevant, the priority is ensuring the patient's safety concerning potential allergic reactions.

Performing a neurological assessment is incorrect. Although neurological status is important, it does not take precedence over confirming allergies before the procedure.

For the correct answer choice:
To mechanically debride necrotic tissue from the wound is correct. Wet-to-dry dressings are primarily used to mechanically debride the wound. As the dressing dries, it adheres to dead tissue, and when removed, it pulls away necrotic material, promoting wound healing by secondary intention.

For incorrect answer choices:
To maintain a moist wound environment for optimal healing is incorrect. Wet-to-dry dressings are not intended to keep the wound moist, but rather to allow the dressing to dry and mechanically debride the wound.
To prevent the wound from becoming infected with bacteria is incorrect. Wet-to-dry dressings are not designed to prevent infection; they serve as a method for debridement. Wound care techniques such as sterile dressings or antimicrobial dressings are better suited for infection prevention.
To reduce the amount of exudate and keep the wound dry is incorrect. Wet-to-dry dressings are not intended to reduce exudate but rather to assist with the removal of necrotic tissue when the dressing is removed.

For the correct answer choice:
"Use gloves when gardening or handling soil" is correct. Gardening or handling soil can expose individuals with weakened immune systems to pathogens like fungi and bacteria present in the soil. Wearing gloves can help reduce the risk of acquiring an opportunistic infection.

For incorrect answer choices:
"Keep windows closed to avoid exposure to outside air" is incorrect. While it is important to avoid exposure to specific pathogens, simply keeping windows closed is not an effective strategy to prevent infection in individuals with AIDS. Fresh air itself is not harmful.
"Limit fluid intake to avoid bacterial contamination" is incorrect. There is no need to restrict fluid intake; the focus should be on drinking clean, safe water. Properly treated water or bottled water is suitable for consumption.
"Wash fruits and vegetables with hot water before eating" is incorrect. While it is essential to wash fruits and vegetables before eating, using hot water is not necessary. Rinsing them thoroughly under running water is adequate to remove potential contaminants.

Correct: These two statements require further education. Enteric-coated and extended-release capsules require another formulation. The patient is at risk for aspiration, laying flat after liquid was placed in his stomach. The head of the bed should be elevated at 30 to 45 degrees for 60 minutes after bolus feedings or medications.

LEARNING OBJECTIVE

You must be able to provide care for your patients and educate them and their families on how to care for tubes and devices at home. Providing this education is essential to prevent complications.

For the correct answer choice:
Watchful waiting, as hydroceles often resolve spontaneously is correct. Non-communicating hydroceles in infants frequently resolve on their own without intervention by 1-2 years of age.

For incorrect answer choices:
Immediate surgical intervention to prevent future complications is incorrect. Surgery is typically reserved for cases where the hydrocele persists beyond 1-2 years or if it is associated with a hernia.
Frequent scrotal elevation to help reduce swelling is incorrect. Elevation is not necessary in the treatment of hydroceles, as the condition usually resolves independently.
Referral to a physical therapist for scrotal massage therapy is incorrect. There is no role for massage therapy in the treatment of hydroceles, as the fluid will either reabsorb naturally or require surgical intervention if persistent.

For the correct answer choice:
"We sometimes offer fruit juice during meals as an alternative to water" is correct. Fruit juice, even if 100% juice, should be limited due to its high sugar content. It is better to offer water to maintain hydration without excess sugar intake.

For incorrect answer choices:
"We avoid giving our child any foods that pose a choking risk, like whole grapes" is incorrect. This is a safe practice to prevent choking hazards in toddlers. Grapes should be cut into small pieces.
"We encourage our child to try a variety of healthy foods, even if they refuse at first" is incorrect. Encouraging exposure to various healthy foods helps to develop diverse eating habits, even if it requires multiple attempts.
"We limit snacks close to mealtime to ensure our child eats the main meal" is incorrect. Limiting snacks before meals helps increase the likelihood that the child will eat the nutritious foods provided at mealtime.

For correct answer choice:

Notifying the healthcare provider is correct. A fetal heart rate of 178 beats per minute indicates fetal tachycardia, which requires prompt evaluation and intervention by the provider.

For incorrect answer choices:

Encouraging fluids and reassessing is incorrect. While hydration can sometimes help increase fetal activity, it is not the priority when fetal tachycardia is present.

Checking the maternal temperature is incorrect. Although maternal fever can cause fetal tachycardia, the first step is notifying the provider to ensure the fetus is promptly evaluated.

Providing reassurance is incorrect. A fetal heart rate above the normal range should not be considered reassuring, as it may indicate potential fetal distress.

For the correct answer choice:
Adopting a heart-healthy diet and regular exercise is correct. Coronary artery disease, the leading cause of death, can be significantly reduced through lifestyle modifications such as a heart-healthy diet, regular physical activity, and managing blood pressure and cholesterol levels.

For incorrect answer choices:
Annual cancer screenings starting at age 40 is incorrect. Although cancer screenings are important, they do not directly reduce the risk of the leading cause of death, which is heart disease.
Reducing alcohol consumption to protect the liver is incorrect. While this may help prevent liver diseases such as cirrhosis or liver failure, it does not directly impact the risk of heart disease, the leading cause of death.
Smoking cessation to reduce respiratory disease risk is incorrect. Smoking cessation can lower the risk of respiratory diseases, but the question asks about the leading cause of death, which is heart disease.

Correct: The patient is displaying symptoms of stroke, and you should first focus on the neurological assessment, which includes the motor strength of his extremities.

Incorrect: When a patient has an acute stroke, time is brain, and the focus is assessing his stroke symptoms to make timely decisions on intervention. These can be assessed later unless distress is shown with other body systems.

LEARNING OBJECTIVE

When to utilize focused assessments is crucial to nursing. Critical situations will not only arise in the emergency room or critical care. Nurses must be prepared to focus on and quickly assess the body system involved to ensure timely intervention.

For correct answer choice:
A. Reducing sodium intake to help lower blood pressure is correct. A low-sodium diet is crucial for individuals with hypertension, as excessive sodium intake can cause fluid retention and elevate blood pressure.

For incorrect answer choices:
Increasing caffeine consumption to boost metabolism is incorrect. High caffeine intake can actually increase blood pressure and is not recommended for those with hypertension.
Maintaining a high-fat diet for energy is incorrect. A high-fat diet, especially with saturated and trans fats, can contribute to atherosclerosis, and worsening hypertension.
Including more refined sugars for quick energy is incorrect. Refined sugars can lead to weight gain and insulin resistance, which may negatively impact blood pressure control.

For correct answer choice:
Including a high-fiber diet to improve bowel regularity is correct. High fiber helps in softening the stool and reducing the risk of constipation, which can aggravate diverticulosis. It promotes regular bowel movements and helps in preventing the formation of diverticula.

For incorrect answer choices:
Avoiding whole grains to prevent flare-ups is incorrect. Whole grains are a good source of fiber, and avoiding them could decrease fiber intake, worsening constipation and symptoms of diverticulosis.

Focusing on a high-protein diet to support healing is incorrect. While protein is essential, a high-fiber diet is more specific for managing diverticulosis than a high-protein diet.

Limiting water intake to reduce pressure on the bowel is incorrect. Adequate hydration is important to help fiber work effectively in the digestive tract. Reducing water intake can worsen constipation.

For correct answer choice:

The client needs further instruction because they may not be aware that after a barium swallow study, they should typically follow specific dietary guidelines, such as avoiding certain foods or drinks for a specified time to help clear the barium from their system.

For incorrect answer choices:

The statement about avoiding solid food for a few hours before the test is correct. Clients are usually instructed to refrain from eating solid foods to ensure that the barium can be properly visualized during the study.

The statement about having to drink a thick liquid during the procedure is correct. This indicates that the client understands the nature of the barium used in the test, which can sometimes be thick or chalky in consistency.

The statement about the test helping to evaluate swallowing function is correct. This indicates that the client understands the purpose of the procedure and its implications for their health.

For the correct answer choice:
Reassess the testis in a few months, as spontaneous descent may still occur is correct. It is common for one or both testes to be undescended at birth, but most will descend by 6-12 months of age without intervention.

For incorrect answer choices:
Recommend immediate surgical intervention to reposition the testis is incorrect. Surgery, known as orchiopexy, is generally considered if the testis does not descend by 12 months of age to reduce the risk of complications.
Advise the parents that it is likely the infant only has one testis is incorrect. A non-palpable testis does not necessarily mean it is absent; it could be undescended or located in the abdomen.
Schedule an ultrasound to confirm the presence of an undescended testis is incorrect. Ultrasound is not the first step; physical examination remains the primary method of assessment for an undescended testis.

Correct: You must turn off the fluids.

Incorrect: The correct steps for obtaining blood are: stop the infusion, find the correct lumen for blood draws, scrub vigorously, flush, aspirate, and discard blood, draw blood for specimen, flush again, and then resume fluids.

LEARNING OBJECTIVE

Knowledge of the process is essential when performing procedures. Stopping infusions is vital to obtaining the correct values of laboratory studies because the content and rate of infusion can impact electrolytes and blood counts.

For the correct answer choice:
Age is correct. Age is a non-modifiable risk factor for coronary artery disease, with older adults being at higher risk for developing CAD. Unlike lifestyle factors, age cannot be changed.

For incorrect answer choices:
Physical inactivity is incorrect. Physical inactivity is a modifiable risk factor, as individuals can increase physical activity to help reduce the risk of CAD.
High cholesterol levels are incorrect. While high cholesterol can increase the risk for CAD, it is considered a modifiable risk factor that can be managed with diet, exercise, and medication.
Obesity is incorrect. Obesity is also a modifiable risk factor, as weight loss can be achieved through lifestyle changes, helping to reduce the risk of CAD.

Correct: Call a stroke alert. As a nurse, it is critical to recognize the signs and symptoms of stroke and act quickly to get appropriate help.

Incorrect: Although a rapid response will also get help to the bedside, it does not alert the stroke team, slightly delaying care. Checking vital signs and blood sugar is appropriate but should not delay calling for the stroke team.

LEARNING OBJECTIVE

Recognition and quick reaction when a patient has a complication is crucial to timely intervention and care. These actions can make the difference between devastating neurologic sequela or minimal.