Nurse is receiving provider prescription by phone for morphi...

Nurse is receiving provider prescription by phone for morphine for client who is reporting moderate to severe pain. Which of the following actions are appropriate? (Select all that apply.)

A. Repeat details of prescription back to provider
B. Have another nurse listen to phone prescription
C. Obtain prescriberâ€™s signature on prescription within 24 hours
D. Decline verbal prescription b/c it is not emergency situation
E. Tell charge nurse that the provider has prescribed morphine by phone

Correct Answer: A, B, C

Rationale: Correct Answer: A, B, C

Rationale:
A: Repeating details back ensures accurate transcription and comprehension.
B: Having another nurse listen ensures a second verification of the prescription.
C: Obtaining the prescriber's signature within 24 hours ensures legal compliance and accountability.

Incorrect Choices:
D: Declining the prescription could delay pain relief for the client.
E: Informing the charge nurse alone does not ensure proper documentation and accountability.

Nurse preparing wellness presentation for families at community center. When discussing health screenings for adolescents, which info about scoliosis should nurse include?

A. "scoliosis is more common in girls than in boys"
B. loss of height is often first sign of scoliosis
C. scoliosis screening is essential during adolescent growth spurt
D. slouching is common cause of scoliosis, esp. in adolescents
E. scoliosis is forward curvature of spine

Correct Answer: A, C

Rationale: Correct Answer: A, C

Rationale:
A: "Scoliosis is more common in girls than in boys" - Correct. Scoliosis is indeed more prevalent in girls, especially during adolescence.
C: "Scoliosis screening is essential during adolescent growth spurt" - Correct. Screening during growth spurts is crucial for early detection and intervention.

Summary:
B: Loss of height as the first sign of scoliosis is incorrect, as it is not a common symptom.
D: Slouching is not a cause of scoliosis; it is a misconception.
E: Scoliosis is a sideways curvature of the spine, not a forward curvature.

Nurse talking to parents of school-age child who describe many issues that concern them. Which problem should nurse identify as priority for more assessment & intervention?

A. He doesn't keep up with other kids in activities like running & jumping
B. He keeps trying to find ways around household rules; he always wants to make deals with us
C. We think he is trying too hard to excel in math just to get top grades in his class
D. He is always afraid the kids at school will laugh at him b/c he likes to sing & write poems

Correct Answer: A

Rationale: The correct answer is A because the child's inability to keep up with other kids in physical activities like running and jumping could indicate underlying physical or developmental issues that require further assessment and intervention. This could be a sign of motor skill delays, muscle weakness, or coordination problems that may impact the child's overall physical health and well-being. Options B, C, and D focus on behavioral, academic, and social issues which are important but not as urgent as addressing potential physical limitations that could affect the child's daily functioning and quality of life.

Nurse is admitting older adult who lost 4.5 kg since last admission 6 months ago. Which questions should nurse ask to investigate source of weight loss?

A. "Do you eat alone or with someone?"
B. Do you watch TV while eating your meals?
C. Have you started any new meds in past 6 months?
D. What foods have you eaten in past 24 hours?
E. Are you on a fixed income?

Correct Answer: A, C, D, E

Rationale: Correct Answer: A, C, D, E

Rationale:
A. "Do you eat alone or with someone?" - This question helps determine social eating habits and potential lack of appetite due to loneliness.
C. "Have you started any new meds in the past 6 months?" - This helps identify medication side effects that may cause weight loss.
D. "What foods have you eaten in the past 24 hours?" - This assesses dietary intake and nutritional status.
E. "Are you on a fixed income?" - Financial constraints can impact food choices and access to nutritious meals.

Summary:
B. "Do you watch TV while eating your meals?" - This does not directly address the potential reasons for weight loss in an older adult.
F. - No information given to evaluate this choice.
G. - No information given to evaluate this choice.

Nurse counseling middle adult who describes having difficulty with many issues. Which problem should nurse identify as priority for more assessment & intervention?

A. "I'm struggling to accept my parents are aging & need so much help"
B. It's been so stressful for me to think about having intimate relationships
C. I know I should volunteer my time for good cause, but maybe I'm just selfish
D. I love my grandchildren, but my son expects me to relive my parenting days

Correct Answer: B

Rationale: The correct answer is B. The nurse should prioritize assessing and intervening in the middle adult's difficulty with intimate relationships because it can significantly impact their emotional well-being and ability to form healthy connections. Intimate relationships play a crucial role in one's overall quality of life and can affect various aspects of mental health. By addressing this issue first, the nurse can help the individual work through their stress and potentially improve their relationships and overall psychological health.

Choices A, C, and D are not as critical as choice B because they involve different aspects of the individual's life that may not have an immediate impact on their emotional well-being and relationships. While accepting aging parents or volunteering are important, they do not directly address the middle adult's current emotional distress. Similarly, the expectation from the son regarding grandparenting, while challenging, may not be as urgent as addressing the stress related to intimate relationships.

Nurse on med-surg unit is informed that mass casualty event occurred & it's necessary to discharge clients to make beds available for injury victims. Which clients can be safely discharged? (Select all that apply.)

A. Client who's dehydrated & receiving IV fluid/electrolytes
B. Client with NG tube to treat small bowel obstruction
C. Client who's scheduled for TURP (prostate resection)
D. Client who is 24h post-op after mastectomy
E. Client scheduled for appendectomy

Correct Answer: C,D

Rationale: Correct Answer: C, D

Rationale:
1. Client scheduled for TURP (prostate resection): This client can be safely discharged as the procedure is elective and not urgent.
2. Client who is 24h post-op after mastectomy: This client is stable post-operation and can be discharged with appropriate follow-up care.

Summary of other choices:
A: Client who's dehydrated & receiving IV fluid/electrolytes - This client needs continued treatment and monitoring.
B: Client with NG tube to treat small bowel obstruction - This client requires ongoing treatment and observation.
E: Client scheduled for appendectomy - This client needs urgent surgical intervention and cannot be safely discharged.