Nokea
A 9-month-old with glaucoma requires surgery. The infant's parents are divorced. To obtain informed consent, which action would be most appropriate?
- A. Contacting the father for informed consent
- B. Obtaining informed consent from the mother
- C. Seeking a court ruling on the course of care
- D. Determining sole or joint custody by the parents
Correct Answer: D
Rationale: The most appropriate action would be to determine legal custody by court decree. If the parents have joint custody, then either parent may give consent, but it is always best to have consent given by both parents.
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The nurse makes an error of omission. What is an example of an error of omission?
- A. placing the fetal monitor incorrectly
- B. not recording input/output amounts
- C. not covering the computer screen when documenting
- D. removing an IV
Correct Answer: B
Rationale: The correct answer is B because not recording input/output amounts can lead to missed vital information affecting patient care. Omission errors involve failing to perform a required action. Placing the fetal monitor incorrectly (A) is an error of commission, actively doing something incorrectly. Not covering the computer screen (C) is a breach of patient confidentiality, not an omission error. Removing an IV (D) is an active intervention, not an omission error.
The nurse is describing the difference between community-based nursing and community health nursing. What response best describes the difference?
- A. A community-based nurse would provide care in a mobile unit in the neighborhood.
- B. A community-based nurse only provides education.
- C. A community health nurse performs cardiac assessments.
- D. A community health nurse only provides hands-on care.
Correct Answer: A
Rationale: The correct answer is A because community-based nursing involves providing care directly to individuals and families within the community, often in non-traditional settings like mobile units or homes. This differs from community health nursing, which focuses on promoting and protecting the health of populations. Choice B is incorrect because community-based nurses do more than just provide education. Choice C is incorrect as cardiac assessments are a specific task that may not always be performed by community health nurses. Choice D is incorrect as community health nurses also provide a range of services beyond hands-on care.
What client statement would most influence the nurse's teaching regarding contraceptive choices?
- A. I have 2 children.
- B. My partner and I have sex twice a week.
- C. I am 25 years old.
- D. I feel funny touching my private parts.
Correct Answer: D
Rationale: Comfort with intimate touch influences method selection.
The nurse is aware that a pre-term neonate may have a potential nutritional problem because of:
- A. Poor sucking reflex
- B. A decreased metabolic rate
- C. Decreased caloric requirement
- D. Increased absorption of nutrients
Correct Answer: A
Rationale: Pre-term infants often have an immature sucking reflex.
When planning a healthy diet with a pregnant patient, what should the nurse's first action be?
- A. Teach the patient about MyPlate.
- B. Review the patient's current dietary intake.
- C. Instruct the patient to limit the intake of fatty foods.
- D. Caution the patient to avoid large doses of vitamins, especially those that are fat-soluble.
Correct Answer: B
Rationale: The correct answer is B because reviewing the patient's current dietary intake is essential to assess their nutritional status and identify areas for improvement. This step helps the nurse understand the patient's eating habits, preferences, and potential deficiencies, laying the groundwork for personalized dietary recommendations. Option A is incorrect because teaching about MyPlate is premature without understanding the patient's current diet. Option C is incorrect as blanket advice to limit fatty foods may not be suitable for all pregnant patients. Option D is incorrect as cautioning about vitamins should come after assessing the patient's current intake to avoid unnecessary restrictions.