Nokea
A nurse is caring for a client whose child died from cancer. The client states 'it's hard to go on without him'. which of the following questions should the nurse ask the client first?
- A. What has helped you through difficult times in the past?
- B. Has anyone in your family committed suicide?
- C. Is there anyone you would like involved in your care?
- D. Are you thinking about ending your life?
Correct Answer: D
Rationale: The correct answer is D: Are you thinking about ending your life? This question is crucial as it directly addresses the client's statement about finding it hard to go on. It assesses the client's suicidal ideation and determines the level of risk for self-harm or suicide. It prioritizes the client's safety and well-being.
Choice A is incorrect because it does not directly address the immediate concern of potential suicide risk. Choice B is irrelevant and may lead to unnecessary distress for the client. Choice C is important but not as urgent as assessing for suicidal ideation.
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Which of the following responses should the nurse make?
- A. Tell me what concerns you about the bedpan
- B. Make sure to use nearby furniture to support yourself when walking to the bathroom.
- C. I will have the physical therapist ambulate you to the bathroom.
- D. You have to use the bedpan for your own safety.
Correct Answer: A
Rationale: The correct answer is A: "Tell me what concerns you about the bedpan." This response demonstrates active listening and empathy, allowing the nurse to understand the patient's specific worries or fears. It promotes patient-centered care by addressing the individual's needs. Other options lack this patient-centered approach: B assumes the patient can walk, C delegates without assessing the patient's concerns, and D is directive and dismissive of the patient's feelings.
Which finding should the nurse identify as an indication that the medication is effective?
- A. Heart rate 140/min
- B. Capillary refill 3 seconds
- C. Cessation of nocturnal enuresis
- D. Absence of hypoglycemic episodes
Correct Answer: C
Rationale: The correct answer is C: Cessation of nocturnal enuresis. This indicates the medication is effective because it shows improvement in the condition being treated, which in this case is nocturnal enuresis. Nocturnal enuresis is the involuntary passage of urine during sleep and it can be a result of various factors such as hormonal imbalance or bladder control issues. Therefore, if the medication is effective, it should lead to the cessation of this symptom.
Heart rate (A) and capillary refill (B) are not necessarily indicators of the effectiveness of the medication in treating nocturnal enuresis. Absence of hypoglycemic episodes (D) is more related to diabetes management rather than nocturnal enuresis.
Which complication should the nurse monitor for?
- A. Contractions
- B. Increased fetal movement
- C. Hypertension
- D. Hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Contractions. Nurses should monitor for contractions as they could indicate preterm labor or other complications. Increased fetal movement (B) is not necessarily a complication but could be a sign of fetal well-being. Hypertension (C) is important to monitor but may not be directly related to the current situation. Hypoglycemia (D) is also important but not typically a primary concern in this situation.
A nurse is preparing to admit a six-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
- A. Assign the child to a negative air pressure room (airborne)
- B. Place the child in a semi-private room with another child who has varicella
- C. Require the child to wear a surgical mask at all times
- D. Ensure the child's visitors wear droplet precautions
Correct Answer: A
Rationale: The correct answer is A: Assign the child to a negative air pressure room (airborne). This is because varicella (chickenpox) is transmitted through airborne droplets. Placing the child in a negative air pressure room helps prevent the spread of the virus to others.
B: Placing the child in a semi-private room with another child who has varicella increases the risk of spreading the infection to each other.
C: Requiring the child to wear a surgical mask at all times may help reduce the spread of droplets, but it does not address the airborne transmission of varicella effectively.
D: Ensuring the child's visitors wear droplet precautions is not sufficient to prevent airborne transmission within the unit.
Which statement should the nurse make?
- A. Bend at the waist when lifting objects from the floor.
- B. Keep the object close to your body when lifting.
- C. Twist your torso while lifting to maintain balance.
- D. Lift heavy objects quickly to reduce strain on the muscles.
Correct Answer: B
Rationale: The correct answer is B: Keep the object close to your body when lifting. This statement is correct because keeping the object close to the body reduces the strain on the back muscles and promotes proper lifting mechanics. By keeping the object close, the center of gravity is maintained, reducing the risk of injury.
Incorrect answers:
A: Bending at the waist when lifting can strain the lower back.
C: Twisting the torso while lifting can lead to back injuries.
D: Lifting heavy objects quickly can increase the risk of muscle strains and injuries.