the nurse has given discharge instructions to parents of a child on phenytoin dilantin which of the following statements suggests that the teaching wa
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Nursing Elites

HESI RN

HESI Nutrition Practice Exam

1. The parents of a child on phenytoin (Dilantin) have received discharge instructions from the nurse. Which of the following statements suggests that the teaching was effective?

Correct answer: B

Rationale: The correct answer is B. Proper oral hygiene, including brushing and flossing carefully after every meal, is essential for children on phenytoin to prevent gingival hyperplasia, a common side effect. Choice A is incorrect because acne is not a common side effect of phenytoin and does not require immediate healthcare provider notification. Choice C is incorrect because vomiting or fever should not prompt skipping a dose without consulting the healthcare provider first. Choice D is incorrect because discontinuing phenytoin should never be done abruptly or without healthcare provider guidance, even if the child is seizure-free for 6 months.

2. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response?

Correct answer: C

Rationale: Diuretics must be continued to control fluid retention, as stopping them can lead to worsening of congestive heart failure.

3. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is

Correct answer: D

Rationale: Assessing pupil responses is crucial in a client with hypertensive crisis to monitor for signs of increased intracranial pressure, which can indicate potential neurological complications. While heart rate, pedal pulses, and lung sounds are important assessments, they do not take precedence over neurological assessments in this critical situation.

4. After a myocardial infarction, a client is placed on a sodium-restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate?

Correct answer: D

Rationale: The correct answer is D. A meal of turkey, sweet potato, green beans, milk, and an orange is low in sodium and suitable for a post-MI diet. Choice A includes a baked potato and canned beets, which are higher in sodium. Choice B includes canned salmon, which can be high in sodium. Choice C includes a bologna sandwich, which is also high in sodium compared to the other options.

5. 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?

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.

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