Nokea
A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past six months. The nurse should assess the woman for other symptoms of:
- A. climacteric.
- B. menopause.
- C. perimenopause.
- D. postmenopause.
Correct Answer: C
Rationale: Perimenopause refers to a period of time in which hormonal changes occur gradually, ovarian function diminishes, and menses become irregular. Perimenopause lasts approximately five years. Climacteric is a term applied to the period of life in which physiologic changes occur and result in cessation of a woman's reproductive ability and lessened sexual activity in males. The term applies to both genders. Climacteric and menopause are interchangeable terms when used for females. Menopause is the period when permanent cessation of menses has occurred. Postmenopause refers to the period after the changes accompanying menopause are complete.
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Which of the following statements is true about a post-discharge follow-up?
- A. The nurse should ensure the client is educated on their discharge instructions.
- B. If the client seems stable, they likely do not need a follow-up visit.
- C. The physician is responsible for making sure the client has their prescriptions upon discharge.
- D. If the client has questions, the nurse should instruct the client to bring them up at their follow-up appointment.
Correct Answer: A
Rationale: The nurse is responsible for ensuring the client is educated, they have their prescriptions, and all their questions are addressed prior to discharge. A client should always have a follow-up visit scheduled with their provider.
A newborn baby exhibits a reflex that includes: hand opening, abducted and extended extremities following a jarring motion. Which of the following correctly identifies the reflex?
- A. ATNR reflex
- B. Startle reflex
- C. Grasping reflex
- D. Moro reflex
Correct Answer: D
Rationale: The moro reflex has all of the listed characteristics.
Which of the following is true about use of technology when caring for a client?
- A. If the nurse does not have time to complete their charting, it is appropriate to take a lunch break and then return to charting.
- B. Medications should be reported promptly.
- C. When researching a client's condition, any available sources can be used.
- D. Computers should only be used for charting purposes during the shift.
Correct Answer: B
Rationale: All charting should be accurate and timely. Computers can be used to look up information related to a client's condition or treatment, but the reliability of sources should be confirmed.
Which of the following factors can impact an individual's ability to give informed consent?
- A. IQ
- B. educational level
- C. pain medications
- D. financial status
Correct Answer: C
Rationale: Pain medications might alter alertness, thought processes, and reactions. It is recommended that a client be approached for consent at least 4 hours after the last dose of pain medicine to allow minimal impact. IQ and educational levels might have a bearing on how information is presented through the discussion process, but they do not have a bearing on informed-consent decision-making.
A client is refusing to stay in the hospital because he does not agree with his healthcare treatment plan. The nurse stops the client from leaving due to concern for his health. Which of these legal charges could the nurse face?
- A. False imprisonment, as the nurse is not allowing the client to leave as he has decided to.
- B. Malpractice, as the nurse is intentionally keeping the patient from making his own decisions, thus violating that nursing duty.
- C. Invasion of privacy, as the nurse is getting involved in the patient's private decisions regarding healthcare.
- D. Negligence, as the nurse ignored the clients right to choose with regard to his healthcare.
Correct Answer: A
Rationale: Refusing to let a client leave against medical advice (AMA) is a form of false imprisonment and is a legal issue for nurses.