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 question to ask first is D: "Are you thinking about ending your life?" This is important to assess the client's risk of suicide, as the statement "It's hard to go on without him" can indicate suicidal ideation. It is crucial to address safety concerns immediately. Asking about coping strategies (A) can come later. Inquiring about family suicide history (B) may not be relevant at this stage. Involving others in care (C) is important but not as urgent as assessing suicidal thoughts.
You may also like to solve these questions
The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply
- A. Provide a low-stimulation environment
- B. Maintain bed rest
- C. Give antihypertensive medication.
- D. Administer betamethasone
- E. Monitor intake and output hourly
- F. Obtain a 24-hr urine specimen
- G. Perform a vaginal examination every 12 hr
Correct Answer: A, B, C, D, E, F
Rationale: Correct Answer: A, B, C, D, E, F
Rationale:
A: Providing a low-stimulation environment promotes rest and reduces stress.
B: Maintaining bed rest may be necessary for certain conditions to prevent complications.
C: Giving antihypertensive medication helps control blood pressure.
D: Administering betamethasone can be part of the treatment plan for certain conditions.
E: Monitoring intake and output hourly helps assess fluid balance and kidney function.
F: Obtaining a 24-hr urine specimen is a common diagnostic test to assess kidney function.
Summary:
Choice G is incorrect as performing vaginal examinations every 12 hours is unnecessary and invasive.
A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching?
- A. I should take antibiotics when I have a virus.'
- B. I can visit my nephew who has chickenpox 5 days after the sores have crusted'
- C. I can clean my cat's litter box during my pregnancy.'
- D. I should wash my hands for 10 seconds with hot water after working in the garden.'
Correct Answer: B
Rationale: The correct answer is B: "I can visit my nephew who has chickenpox 5 days after the sores have crusted." This response indicates understanding of infection prevention because chickenpox is contagious until the sores crust over completely, which usually takes about 5-7 days. Visiting the nephew after this period reduces the risk of contracting the virus.
Incorrect options:
A: Taking antibiotics for a virus is ineffective as antibiotics only work against bacterial infections, not viruses.
C: Cleaning a cat's litter box can expose pregnant individuals to toxoplasmosis, a parasitic infection harmful to the fetus.
D: Washing hands for only 10 seconds with hot water is insufficient to effectively remove germs. The CDC recommends washing for at least 20 seconds with soap and water.
Drag words from the choices below to fill in each blank in the following sentence. The client is at greatest risk for developing-----and-----
- A. Placental Abruption
- B. Hypoglycemia
- C. Heart failure
- D. Cervical insufficiency
- E. Seizures
Correct Answer: C,E
Rationale: The correct answer is C, Heart failure, and E, Seizures. The client is at greatest risk for developing heart failure and seizures due to complications during pregnancy. Heart failure can occur due to the increased stress on the heart from pregnancy, especially in individuals with pre-existing heart conditions. Seizures can arise from conditions like eclampsia, which is a severe form of preeclampsia characterized by high blood pressure and organ damage. Placental abruption (A) is a separation of the placenta from the uterus, not directly related to heart failure or seizures. Hypoglycemia (B) is low blood sugar levels, which may occur but is not the greatest risk in this scenario. Cervical insufficiency (D) is the inability of the cervix to stay closed during pregnancy, which is not directly linked to heart failure or seizures.
A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Replace the carpet with hardwood floors
- B. Encourage physical activity prior to bedtime
- C. Wear clothing with zippers instead of buttons
- D. Place locks at the tops of exterior doors
Correct Answer: D
Rationale: The correct answer is D: Place locks at the tops of exterior doors. This is important because individuals with Alzheimer's disease may wander and become lost. Placing locks at the tops of exterior doors can help prevent the client from leaving the home unsupervised and potentially getting lost or injured.
A: Replacing the carpet with hardwood floors is not directly related to the safety of the client with Alzheimer's disease.
B: Encouraging physical activity prior to bedtime may actually disrupt sleep patterns for individuals with Alzheimer's disease.
C: Wearing clothing with zippers instead of buttons may not significantly impact the client's safety.
Overall, option D is the most appropriate choice to ensure the safety and well-being of the client with Alzheimer's disease.
A nurse is providing discharge teaching to a client following a total gastrectomy. The nurse should instruct the client about which of the following medications?
- A. Ranitidine
- B. Vitamin B12
- C. Vitamin K
- D. Metoclopramide
Correct Answer: B
Rationale: The correct answer is B: Vitamin B12. Following a total gastrectomy, the client will have reduced intrinsic factor production, leading to vitamin B12 deficiency. Supplementing with Vitamin B12 is crucial to prevent pernicious anemia. Ranitidine (A) is a gastric acid reducer and is not necessary after gastrectomy. Vitamin K (C) is primarily produced in the intestines and is not directly impacted by gastrectomy. Metoclopramide (D) is a prokinetic agent used for gastric motility and is not essential post-gastrectomy.