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A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first?
- A. Refer the family to a grief support group
- B. Determine the roles of individual family member
- C. Encourage the family to assign specific tasks to individual family members.
- D. Assist the family to establish a daily routine.
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This should be the first action because understanding each family member's roles can help identify their needs, strengths, and how they can support each other. By determining roles, the nurse can establish a foundation for building effective coping strategies and addressing specific concerns within the family unit.
Incorrect choices:
A: Refer the family to a grief support group - This could be beneficial later on, but it's important to first understand the family dynamics and individual roles.
C: Encourage the family to assign specific tasks to individual family members - Assigning tasks may not address the underlying emotional needs of the family members.
D: Assist the family to establish a daily routine - While routines can be helpful, understanding roles is crucial for tailoring the routine to the family's specific situation.
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The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
- A. Urine protein
- B. Fetal activity
- C. Blood pressure
- D. Urine ketones
- E. Respiratory rate
- F. Report of headache
- G. Gravida/parity
Correct Answer: A, B, C, F
Rationale: The correct answer includes findings that are indicative of potential prenatal complications.
A: Urine protein can indicate preeclampsia, a serious condition in pregnancy.
B: Fetal activity changes may suggest fetal distress or growth restriction.
C: Blood pressure changes can indicate hypertension or preeclampsia.
F: Headache can be a symptom of preeclampsia or other serious conditions.
Choices D, E, and G are not typically associated with prenatal complications. D: Urine ketones may indicate dehydration but not necessarily a prenatal complication. E: Respiratory rate is not directly related to prenatal complications. G: Gravida/parity information is important for obstetric history but not directly indicative of current prenatal complications.
A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?
- A. You should consider taking a sleeping pill before bed each night.'
- B. It is always difficult caring for someone who is terminally ill.'
- C. I am sure you're doing a great job taking care of your mother.'
- D. I can give you information about respite care if you are interested.'
Correct Answer: D
Rationale: The correct response is D: "I can give you information about respite care if you are interested." This is the best response because it addresses the son's lack of sleep, which is a common issue for family caregivers. Offering information about respite care can provide the son with the opportunity to take a break and get some rest while ensuring his mother's needs are still met. It shows empathy and support for his situation.
Choice A is incorrect because suggesting a sleeping pill does not address the underlying issue of caregiver stress and may not be the best solution. Choice B is incorrect as it is a general statement and does not offer any practical help or support. Choice C, while supportive, does not provide a solution to the son's lack of sleep.
A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke. Which of the following information is the priority for the nurse to discuss?
- A. Reviewing information about support groups for individuals who have had a stroke
- B. Obtaining an alert system to get help in case of a fall
- C. Providing information about available transportation resources
- D. Choosing an agency to provide home physical therapy
Correct Answer: B
Rationale: The correct answer is B: Obtaining an alert system to get help in case of a fall. This is the priority because the client's left-sided weakness puts them at risk for falls, which can have serious consequences. Having an alert system ensures they can get immediate help if a fall occurs, potentially preventing injuries or complications. Reviewing support groups (A) can be beneficial but is not as urgent. Providing transportation resources (C) and choosing a home physical therapy agency (D) are important but do not address the immediate safety concern of potential falls.
A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?
- A. Tachycardia
- B. Dry cough
- C. Dyspnea
- D. Hypotension
Correct Answer: C
Rationale: The correct answer is C: Dyspnea. Dyspnea in a postoperative client with a history of pulmonary embolism indicates a potential respiratory complication, which could be life-threatening. The priority is to report this finding to the provider for prompt evaluation and intervention to prevent further complications. Tachycardia (A) and hypotension (D) may also be concerning but dyspnea takes precedence due to its association with pulmonary embolism. A dry cough (B) may be a common postoperative symptom and not necessarily urgent.
A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender?
- A. The client has a history of alcohol use disorder
- B. The client has a history of asthma.
- C. The client takes vitamin C daily
- D. The client takes furosemide twice daily
Correct Answer: B
Rationale: The correct answer is B. Lavender oil can exacerbate asthma symptoms due to its potential to irritate the respiratory system. Asthma is a contraindication because it can trigger or worsen asthma attacks. Alcohol use disorder (A), vitamin C intake (C), and furosemide use (D) are not contraindications for using lavender oil. Alcohol use disorder does not directly interact with lavender oil. Vitamin C intake and furosemide use do not have known interactions with lavender oil that would contraindicate its use.