Nokea
Which of the following manifestations should the nurse expect?
- A. Shortness of breath
- B. Dizziness
- C. Epistaxis
- D. Headache
Correct Answer: B
Rationale: Dizziness reflects reduced circulating volume.
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A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
- A. Document the client's behavior prior to being placed in seclusion,
- B. Assess the client's behavior once every hour
- C. Offer fluids every 2 hr.
- D. Discuss with the client his inappropriate behavior prior to seclusion
Correct Answer: A
Rationale: The correct answer is A: Document the client's behavior prior to being placed in seclusion. This is important for legal and clinical reasons as it provides a clear record of the client's behavior leading up to seclusion, ensuring transparency and accountability. Assessing behavior once every hour (choice B) may not be sufficient for monitoring the client's condition in seclusion. Offering fluids every 2 hours (choice C) is important for hydration but not directly related to seclusion. Discussing inappropriate behavior with the client (choice D) may escalate the situation and is not recommended in this scenario.
Which of the following actions should the nurse take?
- A. Refer the adolescent to a local mental health clinic.
- B. Advise the adolescent to place the newborn for adoption
- C. Contact the adolescent's parent for assistance
- D. Assist the adolescent in applying for Medicaid
Correct Answer: D
Rationale: Medicaid can provide financial assistance for prenatal care and delivery.
Which of the following actions should the nurse take?
- A. Use the palpatory method to determine blood pressure
- B. Place the arm above the level of the client's heart.
- C. Apply the largest cuff available.
- D. Deflate the cuff quickly.
Correct Answer: A
Rationale: The palpatory method can help obtain a more accurate reading when sounds are difficult to auscultate.
Select the 5 findings the nurse should plan to include in the report.
- A. Client's report of lack of food in home
- B. ECG results
- C. Numerous bruises in various stages of healing
- D. Client's avoidance of eye contact
- E. Client's report of lack of access to bank accounts
- F. Client’s report of weight loss
Correct Answer: A,C,D,E,F
Rationale: These findings highlight potential abuse and neglect indicators.
A nurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following actions should the nurse take?
- A. Use leading statements to obtain information from the child
- B. Ensure that multiple nurses are present for the physical examination
- C. Explain to the child what will happen when the abuse is reported
- D. Reassure the child that no one will be told about the abuse
Correct Answer: C
Rationale: Correct Answer: C - Explain to the child what will happen when the abuse is reported.
Rationale: It is crucial for the nurse to inform the child about the reporting process to ensure transparency and build trust. This empowers the child and helps them understand the next steps. It also promotes their involvement in decision-making regarding their well-being. By explaining the process, the nurse can offer emotional support and reassurance to the child. This approach respects the child's autonomy and dignity.
Incorrect Choices:
A: Using leading statements can influence the child's responses and compromise the accuracy of information obtained.
B: Having multiple nurses present may intimidate the child and breach confidentiality.
D: Reassuring the child that no one will be told about the abuse may perpetuate feelings of isolation and hinder the necessary intervention.