Nokea
A pregnant client comes into the prenatal clinic accompanied by her spouse. The spouse states they were in a car accident and his wife's abdomen hit the steering wheel. The nurse observes the client wringing her hands and not making eye contact. The client's record shows two recently missed prenatal appointments. Which action does the nurse take?
- A. Make eye contact with the client and ask about the accident.
- B. Accompany the client into the restroom to obtain a urine sample.
- C. Ask the husband if the wife had been drinking alcohol.
- D. Escort the couple to an examining room to await the health care provider.
Correct Answer: D
Rationale: Escorting the couple to an examining room prioritizes a safe, private assessment of the client’s condition post-accident, especially given signs of possible abuse (missed appointments, anxiety). Direct questioning or accusations may escalate tension, and a urine sample is not the priority.
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A client diagnosed with diabetes mellitus has expressed frustration with learning the diabetic regimen and insulin administration. Which should be the initial action by the home care nurse?
- A. Attempt to identify the cause of the frustration.
- B. Call the primary health care provider to discuss the client's problem.
- C. Offer to administer the insulin on a daily basis until the client is ready to learn.
- D. Continue with teaching, knowing that the client will overcome any frustrations.
Correct Answer: A
Rationale: The home care nurse must determine what is causing the client's frustration. The issue needs to be addressed by the nurse before involving the provider. Administering the insulin provides only a short-term solution. Continuing to teach may only further block the learning process.
The nurse is preparing to care for a child with anemia from a culture that is different from the nurse's. Which is the best way to address the cultural needs of the child and family when the child is admitted to the health care facility?
- A. Address only those issues that directly affect the nurse's care of the child.
- B. Ask questions, and explain to the family why the questions are being asked.
- C. Explain that cultural practices need to be discontinued during hospitalization.
- D. Ignore cultural needs because they are not important to health care professionals.
Correct Answer: B
Rationale: When caring for individuals from a different culture, it is important to ask questions about their specific cultural needs and means of treatment. An understanding of the family's beliefs and health practices is essential to successful interventions for that particular family. Eliminate the options that ignore the cultural beliefs and values of the client.
The nurse is assessing a client who was admitted to the hospital with a diagnosis of urinary calculi. The client received 4 mg of morphine sulfate approximately 2 hours previously. The client states to the nurse, 'I'm scared to death that it'll come back.' Based on these statements, which concern should the nurse identify for this client at this time?
- A. Fear of dying
- B. Lack of understanding about the disease process
- C. Anxiety about the anticipation of recurrent severe pain
- D. Retention of urine from the obstruction of the urinary tract by calculi
Correct Answer: C
Rationale: The client stated, 'I'm scared to death that it'll come back.' The anticipation of the recurring pain produces anxiety and threatens the client's psychological integrity. There is no evidence that the client has a calculus in the right ureter. There is also no evidence that the client has lack of knowledge or urinary retention.
A client has a scheduled office visit due to a new diagnosis of diabetes mellitus. The client tells the nurse that he has trouble maintaining proper health due to anxiety regarding the self-administration of insulin. Which teaching/learning strategy should the nurse initially plan to implement?
- A. Teach a family member to give the client the insulin.
- B. Leave a list of instructions at the bedside for practicing the insulin injections.
- C. Insert the needle, and have the client push in the plunger and remove the needle.
- D. Give the injection until the client feels sufficiently confident to preform it alone.
Correct Answer: C
Rationale: Some clients find it difficult to insert a needle into their own skin. For these clients, the nurse might assist by selecting the site and inserting the needle. Then, as a first step in self-injection, the client can push in the plunger and remove the needle. The remaining options place the client in a dependent role.
A client diagnosed with moderate dementia is prescribed oral anticoagulant therapy while hospitalized. The nurse identifies which discharge scenario as being the best support system for successful anticoagulant therapy monitoring?
- A. The client has a home health aide coming to the house for 9 weeks.
- B. The client was going to stay with a daughter in the daughter's home indefinitely.
- C. The client was going to have blood work drawn in the home by a local laboratory.
- D. The client has a good friend living next door who would take the client to the doctor.
Correct Answer: B
Rationale: The client taking anticoagulant therapy should be informed about the medication, its purpose, and the necessity of taking the proper dose at the specified times. If the client is unwilling or unable to comply with the medication regimen, the continuance of the regimen should be questioned. Option 2 provides a direct support system. Clients may need support systems in place to enhance compliance with therapy. Option 1 facilitates reminding the client to take the medication, option 3 facilitates blood work only, and option 4 facilitates medical care.