a nurse is reviewing nutritional guidelines with the parents of a 2 year old toddler which of the following parent statements should indicate to the n
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Nursing Elites

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HESI Fundamentals Test Bank

1. A nurse is reviewing nutritional guidelines with the parents of a 2-year-old toddler. Which of the following parent statements should indicate to the nurse an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C. Offering a variety of foods in small portions is appropriate for a 2-year-old toddler as it helps provide balanced nutrition and allows the child to explore different tastes and textures. Choice A is incorrect because whole milk is recommended up to 2 years old, not until 3 years old. Choice B is incorrect as excessive juice intake can lead to excessive sugar consumption and is not recommended. Choice D is incorrect as popcorn may pose a choking hazard for toddlers and is not a suitable alternative to sweets.

2. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority?

Correct answer: A

Rationale: The correct answer is A: Pain related to ischemia. This nursing diagnosis should have priority because addressing the pain caused by ischemia is crucial in managing the client's myocardial infarction. Pain management is essential not only for the client's comfort but also for improving outcomes and reducing complications. Choices B, C, and D are not the priority in this scenario. Risk for altered elimination: constipation (Choice B) is not as immediate a concern as managing the client's pain. Risk for complication: dysrhythmias (Choice C) may be a potential concern but addressing the client's pain takes precedence. Anxiety related to pain (Choice D) is important to address but should come after managing the pain itself.

3. A client with type 1 diabetes mellitus is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?

Correct answer: A

Rationale: The correct answer is A. Asking the client what can be done to help overcome the fear of self-injections demonstrates empathy, understanding, and a willingness to support the client in addressing their barriers. This approach facilitates open communication, acknowledges the client's feelings, and involves them in the decision-making process. Choices B and C are authoritarian and may increase resistance in the client by being directive and not considering the client's perspective. Choice D, while positive, does not directly address the client's fear and resistance to self-injections, missing the opportunity to explore the underlying issues.

4. A healthcare provider is witnessing a client sign an informed consent form for surgery. Which of the following describes what the healthcare provider is affirming by this action?

Correct answer: A

Rationale: The correct answer is A. When a healthcare provider witnesses a client signing an informed consent form for surgery, they are affirming that the signature on the form belongs to the client. This is crucial for ensuring patient autonomy and informed decision-making. Choices B, C, and D are incorrect because while it is important for the client to understand the risks of surgery, be aware of postoperative care instructions, and have an opportunity to ask questions, these elements are not specifically affirmed by the healthcare provider witnessing the signature.

5. A client has a prescription for a 24-hour urine collection. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take when a client has a prescription for a 24-hour urine collection is to discard the first voiding. This initial voiding is typically not collected to allow for the accurate start of the 24-hour collection period. All subsequent urine voided within the specified time frame is then collected. Including the last voiding in the collection is important to ensure that the full 24-hour period is covered. It is essential to keep the urine cool by storing it in a single container on ice to prevent degradation of components. Instructing the client to stop midstream and finish urinating into the specimen container is not required for a 24-hour urine collection and is an unnecessary step.

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