Nokea
A 14-year-old client confides to the school nurse that she is pregnant, likely in the second trimester, and has not had prenatal care. Which of the following topics should the nurse discuss with the client at this time? Select all that apply.
- A. Desire for adoption planning services
- B. Emotional response to the pregnancy
- C. Family/social support systems
- D. Nutritional habits and substance use
- E. Plan for finishing high school
Correct Answer: A,B,C,D,E
Rationale: All topics are critical: adoption planning, emotional response, support systems, nutrition/substance use, and education planning address the client’s immediate and long-term needs in a sensitive, holistic manner.
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The nurse is caring for a client who performs frequent urinary self-catheterizations. Which of the following client assessments would indicate a potential for a latex allergy? Select all that apply.
- A. History of angioedema with lisinopril
- B. History of epilepsy
- C. Known allergy to avocados and bananas
- D. Known allergy to shellfish
- E. Lip swelling when blowing up balloons
Correct Answer: C,E
Rationale: Allergies to avocados, bananas, and latex (balloons) indicate a potential latex allergy due to cross-reactivity. Angioedema with lisinopril, epilepsy, and shellfish allergies are unrelated to latex sensitivity.
A nurse is asked to float to the telemetry unit because the unit is short-staffed. The nurse is not familiar with this client population and is concerned about providing safe client care. What is the best action by the nurse?
- A. Accept the assignment and ask about what skills need to be performed
- B. Ask the nurse supervisor if a more experienced nurse can go instead
- C. Read the policy and procedure book for the unit before providing care
- D. Refuse to float to the unit because of concerns about client safety
Correct Answer: A
Rationale: Accepting the assignment and clarifying required skills ensures safe care with support, addressing concerns proactively. Refusing or deferring may disrupt staffing, and reading policies delays care.
The health care provider prescribes a multivitamin regimen that includes thiamine for a client with a history of chronic alcohol abuse. The nurse is aware that thiamine is given to this client population for which purpose?
- A. To lower the blood alcohol level
- B. To prevent gross tremors
- C. To prevent Wernicke encephalopathy
- D. To treat seizures related to acute alcohol withdrawal
Correct Answer: C
Rationale: Thiamine prevents Wernicke encephalopathy, a neurological disorder from thiamine deficiency common in chronic alcoholism. It does not lower alcohol levels, prevent tremors, or treat seizures directly.
The nurse is reinforcing health promotion education to the parents of a toddler. Which statement by a parent requires the nurse to clarify teaching?
- A. I will offer my child options rather than asking yes or no questions
- B. I will wait at least 15 minutes after a play period to offer a meal to my child
- C. If my child is having a tantrum, I will have them sit in a quiet area for a short time-out
- D. If my child refuses a meal, I will have them stay at the table until they eat half the food.
Correct Answer: B
Rationale: Waiting 15 minutes after play to offer a meal is unnecessary and may disrupt healthy eating habits. Offering options and using time-outs are age-appropriate parenting strategies.
An unlicensed assistive personnel (UAP), who usually works in pediatrics is assigned to work on a medical-surgical unit. Which one of the questions by the charge nurse would be most appropriate prior to making delegation decisions?
- A. How long have you been a UAP?
- B. What type of care did you give in pediatrics?
- C. Do you have your competency checklist that we can review?
- D. How comfortable are you to care for adult clients?
Correct Answer: C
Rationale: The UAP must be competent to accept the delegated task. Further assessment of the qualifications of the UAP is important in order to assign the right task.