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A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?
- A. The client has surgical hypoparathyroidism and positive Trousseau's sign.
- B. A client who has Clostridium difficile with acute diarrhea
- C. A client who is experiencing acute kidney injury and has urine with a low specific gravity
- D. The client who has oral cancer and reports a sore on his gums
Correct Answer: A
Rationale: The correct answer is A because the client with surgical hypoparathyroidism and positive Trousseau's sign indicates a potential life-threatening condition due to hypocalcemia. Trousseau's sign is a clinical indicator of hypocalcemia, which can lead to serious complications such as seizures and tetany. This client needs immediate intervention to prevent further complications.
Choice B is incorrect because while Clostridium difficile with acute diarrhea requires prompt treatment, it is not as immediately life-threatening as hypocalcemia. Choice C is incorrect as well, as although acute kidney injury is serious, a low specific gravity alone does not necessarily indicate an immediate threat to the client's life. Choice D is also incorrect as oral cancer with a sore on the gums, while concerning, is not an immediate priority compared to the potential life-threatening complications of hypocalcemia.
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After describing the various legislative efforts to address the issue of homelessness in the United States, a nursing instructor determines that the teaching was successful when the students identify which of the following as addressing the need for a continuum of care approach?
- A. Bringing Home America Act
- B. Affordable Care Act
- C. American Recovery and Reinvestment Act
- D. McKinney-Vento Homeless Assistance Act
Correct Answer: D
Rationale: The correct answer is D: McKinney-Vento Homeless Assistance Act. This act addresses the need for a continuum of care approach by providing federal funding for homeless assistance programs that offer a range of services to individuals experiencing homelessness. It emphasizes the importance of coordination among various service providers to ensure a seamless transition from emergency shelters to permanent housing.
Choice A: Bringing Home America Act does not specifically focus on homeless assistance programs or the continuum of care approach.
Choice B: Affordable Care Act primarily focuses on healthcare reform and expanding access to healthcare services, not specifically related to addressing homelessness.
Choice C: American Recovery and Reinvestment Act aims to stimulate economic recovery through job creation and infrastructure projects, not directly related to addressing homelessness or providing a continuum of care approach.
As a nurse working in obstetrics, what is one way to mitigate possible causes of intellectual disability?
- A. Explain to the parent the treatment options available.
- B. Explain to the parent environmental risks to avoid during pregnancy.
- C. Explain to the parent that genetics have a role in this disability.
- D. Explain to the parent that learning disabilities often go unnoticed until the child enters school.
Correct Answer: B
Rationale: The correct answer is B because avoiding environmental risks during pregnancy can help mitigate possible causes of intellectual disability. Environmental factors such as exposure to toxins, infections, and poor nutrition can have a significant impact on fetal brain development. By educating parents about these risks, nurses can empower them to make informed choices to protect their baby's cognitive development.
Choice A is incorrect because treatment options are not preventive measures to avoid intellectual disability.
Choice C is incorrect because while genetics can play a role in intellectual disability, it is not something parents can actively mitigate during pregnancy.
Choice D is incorrect because learning disabilities are different from intellectual disabilities, and addressing them at school age is not a preventive measure during pregnancy.
A nurse has just completed a suicide risk assessment of a 76-year-old widowed man. In addition to documenting the presence or absence of suicidal thoughts, plan, and means, the nurse would also document which of the following?
- A. Use of substances 6 hours before the assessment
- B. Speech patterns
- C. Availability of support resources
- D. Amount of sleep in past 24 hours
Correct Answer: A
Rationale: The correct answer is A: Use of substances 6 hours before the assessment. This is important to assess as substance use can increase the risk of impulsive behavior and exacerbate suicidal thoughts. It is crucial to determine if the individual has recently used substances as it may impact their judgment and decision-making. The other choices are not directly related to immediate risk assessment for suicide. Speech patterns (B) may provide insight into the individual's mental state, but substance use takes precedence in assessing immediate risk. Availability of support resources (C) is important for long-term prevention but does not address immediate risk. The amount of sleep in the past 24 hours (D) may impact mental health but does not directly assess immediate risk of suicide.
The statement"Growth involves resolution of critical tasks through the eight stages of the life cycle" is a concept of which therapeutic model?
- A. Interpersonal.
- B. Cognitive-behavioral.
- C. Intrapersonal.
- D. Psychoanalytic.
Correct Answer: A
Rationale: The correct answer is A: Interpersonal. This concept aligns with Erikson's psychosocial theory, which emphasizes the importance of resolving developmental tasks at each stage of life. Interpersonal therapy focuses on relationships and interactions with others, making it the most suitable model for addressing growth through the life cycle. Choice B (Cognitive-behavioral) focuses on thoughts and behaviors, not developmental stages. Choice C (Intrapersonal) refers to self-awareness and understanding, not specifically addressing life stages. Choice D (Psychoanalytic) focuses on unconscious processes and early childhood experiences, not necessarily on resolving tasks through different life stages.
A nurse is performing an assessment interview of a 14-year-old boy who is being admitted to an adolescent substance abuse unit. His parents are concerned about their son's repeated problems at school that they associate with his drug use. The boy stalks into the office, abruptly sits down, crosses his arms, and says, 'Okay, ask your stupid questions, but don't expect me to cooperate!' Which response by the nurse would be most appropriate?
- A. Your attitude is offensive; I can see why your parents brought you here.
- B. Why don't we wait until you've calmed down a bit to start the interview?
- C. Why are you so angry?
- D. You seem pretty upset. Tell me about what is upsetting you.
Correct Answer: D
Rationale: The correct response is D because it acknowledges the boy's emotions, shows empathy, and invites him to share his feelings. By acknowledging his upset feelings, the nurse can build rapport and establish trust, which is crucial in therapeutic communication. This response also opens the door for the boy to express himself and potentially reveal the underlying reasons for his behavior.
Choices A and C are confrontational and judgmental, which can escalate the situation and hinder communication. Choice B suggests waiting until the boy calms down, which may be dismissive of his emotions and doesn't address the immediate need for connection and understanding.