Nokea
A nurse is caring for a person who is blind. What intervention could the nurse implement to deliver culturally responsive care?
- A. Ask family members to leave the room for the discussion of care.
- B. Be aware of how the person is addressed.
- C. Introduce herself with her name and credentials upon entering the room.
- D. Leave education material in Braille on the table across the room from the bed.
Correct Answer: C
Rationale: Introducing oneself clearly helps build trust and ensures the patient knows who is providing care.
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What physical findings would the nurse expect in a bulimic client?
- A. Mastoiditis.
- B. Hirsutism.
- C. Gynecomastia.
- D. Esophagitis.
Correct Answer: D
Rationale: Repeated vomiting damages the esophagus.
A patient is prescribed birth control pills. What should the nurse include in the patient education regarding missed doses?
- A. Take two doses the next day if you miss a dose.
- B. You should take the missed dose as soon as you remember, and take the next dose at the regular time.
- C. If you miss a dose, skip that day and continue as usual the next day.
- D. You should stop taking the pills if you miss a dose and contact your healthcare provider.
Correct Answer: B
Rationale: If a dose is missed, it should be taken as soon as remembered and the next dose taken at the usual time. Choice A is incorrect because taking two doses at once may cause side effects. Choice C is incorrect because missing a dose does not require skipping the next dose. Choice D is incorrect because missing a dose does not typically require stopping the pills, but rather following instructions to compensate for the missed dose.
A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications?
- A. Hyperemesis
- B. Proteinuria
- C. Hypoxia
- D. Hemorrhage
Correct Answer: D
Rationale: Following an amniocentesis, the nurse should observe the client for the potential complication of hemorrhage. Amniocentesis is a procedure where a small amount of amniotic fluid is extracted from the amniotic sac surrounding the fetus for various diagnostic purposes. The risk of hemorrhage is associated with this invasive procedure due to the possibility of damaging blood vessels within the uterus during the insertion of the needle. It is important for the nurse to closely monitor the client for any signs of bleeding, such as vaginal bleeding, abdominal pain, or signs of shock, and report any concerns promptly to the healthcare provider for further evaluation and management.
The nurse is caring for a 14-year-old boy with a growth hormone deficiency. Which action best reflects using the nursing process to provide quality care to children and their families?
- A. Reviewing the effectiveness of interventions
- B. Questioning the facility standards for care
- C. Earning continuing education credits
- D. Ensuring reasonable costs for care provided
Correct Answer: A
Rationale: The nursing process is used to care for the child and family during health promotion, maintenance, restoration, and rehabilitation. Reviewing the effectiveness of interventions is related to outcome evaluation in the nursing process.
A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include?
- A. "Your contraction will become more intense when walking"
- B. "You will have dilation and effacement of the cervix"
- C. You will have bloody show"
- D. "Your contraction will become temporally regular"
Correct Answer: D
Rationale: False labor, also known as Braxton Hicks contractions, are contractions that are irregular and do not lead to cervical dilation and effacement, unlike true labor contractions. During false labor, contractions may feel intense when walking, but they do not become progressively more intense over time, as is seen in true labor. Additionally, false labor contractions do not typically result in bloody show, which is a sign of impending true labor. Therefore, the correct information to include regarding false labor is that contractions will remain temporarily irregular in nature.