Nokea
A nurse is caring for a client following the delivery of a stillborn infant. Which of the following actions should the nurse take? Select all that apply.
- A. Ask the parents if they would like to help bathe the infant
- B. Discourage the parents from naming the infant
- C. Discuss the importance of organ donation with the parents
- D. Encourage the parents and family members to hold the infant
- E. Offer to obtain handprints, footprints, and photographs of the infant
Correct Answer: A,D,E
Rationale: Bathing, holding, and obtaining mementos support grieving. Naming is a personal choice, and organ donation discussions may be inappropriate at this time.
You may also like to solve these questions
A nurse has been assigned to provide care to a client with suicidal ideation who is receiving treatment in an outpatient setting. The nurse develops a care plan and reviews it with the nurse preceptor before meeting with the client. Which proposed nursing action in the care plan requires intervention by the nurse preceptor?
- A. Assist the client in identifying the warning signs of a crisis
- B. Have the client write a list of people to contact for help and distraction
- C. Help the client develop ways of coping with suicidal thoughts
- D. Persuade the client to sign a contract promising not to attempt suicide
Correct Answer: D
Rationale: No-suicide contracts are not evidence-based and may create pressure rather than support coping strategies.
The nurse is preparing to flush a client's central venous catheter. Which size syringe is best for the nurse to choose?
- A. 1 mL
- B. 3 mL
- C. 10 mL
- D. 30 mL
Correct Answer: C
Rationale: A 10 mL syringe is recommended to avoid excessive pressure that could damage the catheter.
The nurse is caring for a client admitted 3 days ago with bacterial pneumonia who has become short of breath, restless, and difficult to rouse. Which additional finding indicates to the nurse that the client may be developing sepsis?
- A. Capillary refill time of 5 seconds
- B. Diminished breath sounds in the lung bases
- C. Hyperactive bowel sounds
- D. Urine output of 35 mL/hr
Correct Answer: A
Rationale: Prolonged capillary refill time suggests poor perfusion, a sign of sepsis, requiring immediate intervention.
The nurse is caring for a client who had a surgical excision and biopsy of a tumor. The biopsy results show that the tumor is malignant, but the client has not yet been informed by the health care provider. The client asks the nurse, 'Am I going to die?' Which of the following responses would be appropriate for the nurse to make?
- A. You seem upset. Tell me more about how you are feeling about this situation.
- B. I understand that you feel anxious. Maybe watching television will help you relax.
- C. Waiting for test results can be very stressful. I am sure that it will all work out.
- D. The biopsy results show that you have cancer. However, many cancers are treatable.
Correct Answer: A
Rationale: Exploring the client's feelings is supportive and appropriate, as the nurse should not disclose results before the provider.
The nurse is monitoring a 12-month-old diagnosed with intussusception. Which findings should the nurse expect? Select all that apply.
- A. Palpable olive-shaped mass in epigastrium
- B. Palpable sausage-shaped mass in upper right quadrant
- C. Projectile vomiting containing blood
- D. Screaming and drawing the knees up to the chest
- E. Stool mixed with blood and mucus
Correct Answer: B,D,E
Rationale: Intussusception is characterized by a sausage-shaped mass, paroxysmal pain with knee-drawing, and 'currant jelly' stools.