Nokea
A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?
- A. A client with AIDS being treated with Foscarnet
- B. A client with a fractured femur in a long leg cast
- C. A client with laryngeal cancer with a laryngectomy
- D. A client with diabetic ulcers on the left foot
Correct Answer: C
Rationale: The correct answer is the client with laryngeal cancer who had a laryngectomy. This client is at risk for airway obstruction due to the surgical procedure, making it a priority visit. Clients with AIDS (choice A), a fractured femur (choice B), and diabetic ulcers (choice D) do not have immediate life-threatening conditions that require urgent attention compared to a client with a recent laryngectomy.
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During a school screening, a nurse notices small bruises on the anterior and posterior ribs of an 8-year-old Asian child. The nurse should ask the child:
- A. if the family practices coining
- B. who performs coinings
- C. if the child has fallen
- D. how long the child has been abused
Correct Answer: A
Rationale: The correct answer is to ask if the family practices coining. In Asian cultures, coining is a traditional practice believed to draw infections from the body. It involves rubbing a heated coin on the chest and torso, which can cause bruising similar to what the nurse noticed on the child's ribs. This question is important to differentiate between cultural practices and potential child abuse. Choices B, C, and D are incorrect because assuming abuse without considering cultural practices can lead to misinterpretation and inappropriate actions. It's crucial for healthcare providers to be culturally sensitive and gather all relevant information before making conclusions.
After talking to the nurse, the charge nurse should:
- A. Report the incident to the Board of Nursing
- B. File a formal reprimand
- C. Terminate the nurse
- D. Charge the nurse with a tort
Correct Answer: B
Rationale: The appropriate action after discussing the problem with the nurse is to document the incident and file a formal reprimand. Reporting to the Board of Nursing may be necessary if the behavior persists or harm occurs to the client, but it is not the initial step. Termination should be considered if the issue continues despite warnings. Charging the nurse with a tort is not a suitable course of action in this situation as a tort refers to a wrongful act against a client or their belongings, not an appropriate disciplinary measure. Therefore, choices A, C, and D are incorrect.
The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical-surgical unit. Which group of clients should she assign to the medical-surgical nurse?
- A. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction
- B. C-section planning discharge, post-partum infection, mastectomy
- C. Vaginal delivery of fetal demise, C-section with pneumonia, 32-week gestation with lymphoma
- D. 28-week gestation of bed rest, post-partum with HELLP syndrome, breast reconstruction
Correct Answer: A
Rationale: The correct answer includes clients who have undergone surgical procedures typically managed on a medical-surgical unit. Choice A consists of clients who have had elective surgical procedures such as hysterectomy, bladder suspension with A&P repair, and breast reduction, which are commonly treated in a medical-surgical setting. Choices B, C, and D involve clients with various complications related to childbirth, fetal demise, pneumonia, gestational lymphoma, HELLP syndrome, and bed rest, which are more complex cases requiring specialized care beyond medical-surgical nursing.
When teaching clients with a diagnosis of Schizophrenia nearing discharge from a residential care facility, what is an essential topic to include?
- A. pathophysiology of the disease and expected symptoms.
- B. how to recognize and manage symptoms of relapse.
- C. the need to take extra medication when feeling stressed.
- D. the importance of contact with follow-up care daily.
Correct Answer: B
Rationale: When educating clients with Schizophrenia nearing discharge, it is crucial to focus on teaching them how to recognize and manage symptoms of relapse. Clients are usually aware of these symptoms, such as feeling anxious and overwhelmed, before the onset of psychosis. This early stage is vital for intervention, which involves finding a safe environment, seeking help, avoiding stressors, and reducing stimuli. Understanding and managing relapse symptoms empower clients to take proactive steps in their care. Choices A and C are not as immediate and practical as recognizing symptoms of relapse for client safety and well-being. While contact with follow-up care is important, it is not as urgent and specific as knowing how to manage relapse symptoms for immediate intervention.
How can the nurse best communicate to a client that he or she has been listening?
- A. restating the main feeling or thought the client has expressed
- B. making a judgment about the client's problem
- C. offering a leading question such as, 'And then what happened?'
- D. saying, 'I understand what you're saying.'
Correct Answer: A
Rationale: The best way for the nurse to communicate to a client that he or she has been listening is by restating the main feeling or thought the client has expressed. Restating helps the client validate the nurse's understanding of the communication, demonstrating active listening skills. Making judgments about the client's problem, as suggested in Choice B, can hinder effective communication by introducing bias and potential misinterpretation. Offering a leading question like in Choice C is not ideal for confirming understanding; it rather seeks more information. Choice D, simply saying 'I understand what you're saying,' may not convey active listening as effectively as restating the client's main feelings or thoughts, as it lacks the validation component present in restating.