Nokea
A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
- A. A client who is receiving heparin for deep-vein thrombosis.
- B. A client who is 1 day postoperative following a vertebroplasty.
- C. A client who has cancer and a sealed implant for radiation therapy.
- D. A client who has COPD and a respiratory rate of 44/min.
Correct Answer: B
Rationale: The correct choice is B: A client who is 1 day postoperative following a vertebroplasty. This client is the most stable among the options provided. Early discharge is appropriate because the client is 1 day postoperative, likely past the critical immediate postoperative period. Discharging this client will create space for incoming emergency admissions. Choice A should not be discharged early as managing deep-vein thrombosis with heparin requires close monitoring to prevent complications. Choice C should not be discharged early due to the need for ongoing cancer treatment. Choice D should not be discharged early as the client with COPD and a high respiratory rate of 44/min requires close monitoring and intervention to prevent respiratory distress.
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A nurse is working in a shelter following a disaster. Which of the following is the priority action for the nurse to take?
- A. Create diversionary activities for children
- B. Address the physical needs of clients
- C. Help clients gather needed supplies
- D. Explore feelings the clients are experiencing
Correct Answer: B
Rationale: The correct answer is B: Address the physical needs of clients. This is the priority action because in a disaster setting, ensuring the basic physical needs of clients such as food, water, shelter, and medical care takes precedence to ensure their survival and well-being. Without addressing these needs first, the clients' health and safety could be compromised. Creating diversionary activities for children (A), helping clients gather supplies (C), and exploring clients' feelings (D) are important but secondary to addressing immediate physical needs. It is crucial to prioritize basic survival needs before addressing emotional or social needs in a disaster situation.
A home health nurse is assessing a client who has AIDS. Which of the following responses by the client indicates a risk for suicide?
- A. I'm afraid of experiencing pain near the end.
- B. I know that everything will be better soon.
- C. I am relying more and more on my partner for support.
- D. I don't want to lose control of my ability to make decisions.
Correct Answer: B
Rationale: The correct answer is B: "I know that everything will be better soon." This response indicates a risk for suicide as it reflects a sense of hopelessness or feeling that things will not improve. This mindset is often associated with suicidal ideation.
A: Fear of pain near the end is a common concern in terminal illnesses but does not directly indicate suicide risk.
C: Relying on a partner for support can be a coping mechanism and does not necessarily indicate suicide risk.
D: Desire to maintain decision-making control is a sign of autonomy and does not directly indicate suicide risk.
In summary, choice B is correct as it suggests a lack of hope for the future, while the other choices do not directly indicate a risk for suicide.
A nurse is caring for a client who is homeless. Which of the following actions should the nurse take first?
- A. Determine the client's understanding of her living situation
- B. Assist the client to develop goals for obtaining shelter
- C. Discuss the risks of being homeless with the client
- D. Develop client teaching using a variety of strategies
Correct Answer: A
Rationale: The correct answer is A: Determine the client's understanding of her living situation. This is the first step because it allows the nurse to assess the client's current situation and needs. Understanding the client's perspective is crucial for providing effective care and support. Assisting the client in developing goals (B) or discussing risks (C) should come after understanding the client's current situation. Developing client teaching (D) is important but should be based on the client's understanding and needs, which is why it comes after assessing their understanding.
An occupational health nurse is discussing health promotion with a client who has a history of obesity. Which of the following comments indicates the client is using rationalization as a coping mechanism?
- A. I have lots of health problems from being obese
- B. I am obese, it's in my genes
- C. I have difficulty resisting the items in vending machines
- D. I know you don't like me because I am obese
Correct Answer: B
Rationale: The correct answer is B because the client is using rationalization by attributing their obesity to genetics rather than taking personal responsibility. This deflects accountability and provides a justification for their weight issue. Choice A acknowledges the health problems related to obesity. Choice C acknowledges a specific struggle with resisting temptations. Choice D reflects projection, attributing dislike to the nurse. Other choices are incomplete.
A nurse is working to reduce individual and family violence in the local community. Which of the following actions by the nurse demonstrates a primary prevention strategy to achieve this goal?
- A. Conducting counseling for at-risk parents
- B. Assessing a family for marital discord
- C. Teaching parenting techniques to new parents
- D. Providing treatment for a young adult who has a substance use disorder
Correct Answer: C
Rationale: The correct answer is C: Teaching parenting techniques to new parents. This is a primary prevention strategy because it focuses on educating parents before any violence occurs. By providing new parents with effective parenting techniques, the nurse is helping to prevent the occurrence of violence in the first place. This intervention addresses the root cause and promotes a positive family environment.
Choices A, B, and D are not primary prevention strategies. Conducting counseling for at-risk parents (A) is a secondary prevention strategy as it aims to intervene with individuals already at risk. Assessing a family for marital discord (B) is also a secondary prevention strategy as it involves identifying existing issues. Providing treatment for a young adult with a substance use disorder (D) is a tertiary prevention strategy, focusing on treating the individual after the issue has already developed.