Nokea
A client who is having suicidal thoughts tells the nurse, "It just doesn't seem worth it anymore. Why not end my misery?" Which of the following responses by the nurse is appropriate?
- A. Why do you think your life is not worth it anymore?
- B. Do you have a plan to end your life?
- C. I need to know what you mean by misery
- D. You can trust me and tell me what you're thinking
Correct Answer: B
Rationale: The appropriate response by the nurse is to ask about the client's plan to end their life. This question helps to assess the severity of the client's suicidal ideation and the immediacy of the risk, allowing the nurse to determine the appropriate level of intervention. Choices A, C, and D do not directly address the immediate risk assessment needed in this situation.
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A client who is at 32 weeks gestation and has a history of cardiac disease is being cared for by a nurse. Which of the following positions should the nurse place the client in to best promote optimal cardiac output?
- A. The chest
- B. Standing
- C. Supine
- D. Left lateral
Correct Answer: D
Rationale: The correct answer is the left lateral position. Placing the client in the left lateral position promotes optimal cardiac output during pregnancy by reducing pressure on the inferior vena cava, improving blood flow to the heart and fetus. Choice A, 'The chest,' is incorrect as it does not describe a position that benefits cardiac output. Choice B, 'Standing,' is incorrect as it does not alleviate pressure on the vena cava. Choice C, 'Supine,' is contraindicated in pregnancy, especially in clients with cardiac disease, as it can compress the vena cava and decrease cardiac output.
A nurse is planning to delegate to an AP the task of fasting blood glucose testing for a client who has diabetes mellitus. Which of the following actions should the nurse take?
- A. Determine if the AP is qualified to perform the test
- B. Help the AP perform the blood glucose test
- C. Assign the AP to ask the client if they have taken diabetic medication today
- D. Have the AP check the medical record for prior blood glucose test results
Correct Answer: A
Rationale: Before delegating any task, the nurse must determine whether the AP is qualified to perform it. In this scenario, verifying the AP's competency to conduct fasting blood glucose testing is crucial for patient safety and compliance with facility protocols. The other choices are incorrect because they do not address the essential step of assessing the AP's ability to perform the delegated task. While helping the AP or assigning tasks related to diabetic medication or medical records are important, the primary concern should be confirming the AP's competence for the specific delegated duty of blood glucose testing.
A nurse is preparing to administer TPN with added fat supplements to a client who has malnutrition. Which of the following actions should the nurse take?
- A. Administer the TPN solution separately from 0.9% sodium chloride
- B. Check for an allergy to eggs
- C. Discuss the TPN solution with the client
- D. Monitor for hypoglycemia
Correct Answer: B
Rationale: The correct action for the nurse to take when preparing to administer TPN with fat supplements is to check for an allergy to eggs. The lipid emulsion in TPN often contains egg phospholipids, so screening for egg allergies is crucial to prevent any adverse reactions. Option A is incorrect because TPN should not be piggybacked with 0.9% sodium chloride to avoid any interactions or dilution of the TPN solution. Option C is incorrect as discussing the TPN solution with the client is not the priority when preparing to administer it. Option D is incorrect as monitoring for hypoglycemia, although important in TPN administration, is not specifically related to the addition of fat supplements.
A nurse is caring for a client who has schizophrenia. Which of the following assessment findings should the nurse expect?
- A. Decreased level of consciousness
- B. Inability to identify common objects
- C. Poor problem-solving ability
- D. Preoccupation with somatic disturbances
Correct Answer: C
Rationale: In clients with schizophrenia, poor problem-solving ability is a common assessment finding due to impaired cognitive function associated with the disorder. This impairment can manifest as difficulties in decision-making and problem-solving. Choice A, decreased level of consciousness, is not a typical finding in schizophrenia. Choice B, inability to identify common objects, is more indicative of conditions like dementia rather than schizophrenia. Choice D, preoccupation with somatic disturbances, is more characteristic of somatic symptom disorder rather than schizophrenia.
A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel telling the client, "If you don't eat, I'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?
- A. Assault
- B. Battery
- C. Malpractice
- D. Negligence
Correct Answer: A
Rationale: The correct answer is A: Assault. Assault is the act of threatening a client with harm, such as the threat of using restraints to force-feed the client, even if no physical contact occurs. In this scenario, the statement made by the assistive personnel constitutes assault because it involves the threat of harm. Choice B, Battery, involves actual physical contact without the client's consent, which is not present in the scenario. Choice C, Malpractice, refers to professional negligence or misconduct, not a direct threat to the client. Choice D, Negligence, involves failure to provide reasonable care that results in harm, which is not applicable in this context.