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A nurse is providing teaching to a client who speaks a different language than the nurse, and an interpreter is present. Which of the following findings should the nurse document to show that the client understands the teaching?
- A. Client smiles at the nurse.
- B. Client asks questions to the interpreter.
- C. Client makes eye contact with the nurse frequently.
- D. Client points to printed resources when the nurse speaks.
Correct Answer: B
Rationale: The correct answer is B: Client asks questions to the interpreter. This indicates that the client is actively engaging with the information being provided, seeking clarification, and demonstrating an understanding of the teaching. Asking questions shows the client is processing the information and trying to make sense of it. Smiling at the nurse (A) may indicate politeness or agreement but does not necessarily reflect comprehension. Making eye contact (C) can show attentiveness but not necessarily understanding. Pointing to printed resources (D) may indicate a desire for more information but doesn't confirm comprehension.
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A school nurse is implementing health screening. Which of the following assessment findings should the nurse recognize as the highest priority?
- A. A child who has a BMI of 18
- B. An adolescent who has scoliosis
- C. An adolescent who has psoriasis
- D. A child who has nits
Correct Answer: B
Rationale: The correct answer is B: An adolescent who has scoliosis. Scoliosis is a spinal deformity that can progress and cause serious health issues if left untreated. The school nurse should prioritize this assessment finding to ensure early detection and appropriate interventions to prevent further complications. A: A child with a BMI of 18 may indicate underweight but is not as urgent as scoliosis. C: Psoriasis is a skin condition that may require management but is not immediately life-threatening. D: Nits (lice eggs) are a common issue but do not pose a significant health risk compared to scoliosis.
A community health nurse is working with a group of clients. The nurse practices the ethical principle of distributive justice by performing which of the following tasks?
- A. Keeping a promise to visit a client who is housebound after the delivery of care.
- B. Ensuring that a client who is homeless receives preventive medical care.
- C. Being honest with the parents of a child about the need to report suspected abuse.
- D. Accepting the decision of an older adult client to live alone in her home.
Correct Answer: B
Rationale: The correct answer is B because distributive justice involves fair distribution of resources and benefits in society. By ensuring that a homeless client receives preventive medical care, the nurse is promoting fairness and equitable access to healthcare services for all individuals, regardless of their social status. This action aligns with the principle of distributive justice by addressing the healthcare needs of a vulnerable population.
Keeping a promise to visit a housebound client (A) demonstrates fidelity rather than distributive justice. Being honest about reporting suspected abuse (C) is related to veracity and duty to protect vulnerable individuals. Accepting the decision of an older adult to live alone (D) is more about respecting autonomy and independence.
A nurse is providing education to a group of adolescents who are pregnant and attending high school. Which of the following information should the nurse include in their teaching?
- A. The need for supplemental folic acid is greatest during the third trimester
- B. The incidence of high birth weight infants is higher in adolescent pregnancy
- C. Pregnant adolescents need to gain less weight than adult mothers
- D. Caffeinated beverages should be replaced with caffeine-free beverages
Correct Answer: D
Rationale: The correct answer is D: Caffeinated beverages should be replaced with caffeine-free beverages. Pregnant adolescents should limit their caffeine intake as excessive caffeine can lead to complications during pregnancy. Caffeine can cross the placenta and affect the baby's heart rate and sleep patterns. It is important for pregnant adolescents to switch to caffeine-free beverages to ensure the health and well-being of both the mother and baby.
A: The need for supplemental folic acid is not specific to the third trimester, it is important throughout pregnancy.
B: The incidence of high birth weight infants is not necessarily higher in adolescent pregnancy compared to adult mothers.
C: Pregnant adolescents actually need to gain weight within the recommended range, similar to adult mothers, to support fetal growth and development.
A home health nurse is caring for a client who has chemotherapy-induced nausea that has been resistant to relief from pharmacological measures. Which of the following interventions should the nurse initiate? (Select all that apply)
- A. Use seasonings to enhance the flavor of foods
- B. Provide sips of room temperature ginger ale between meals
- C. Maintain the head of the client's bed in an elevated position after eating
- D. Offer 120 ml (4 oz.) of cold 2% milk as a meal replacement
- E. Assist the client in using guided imagery
Correct Answer: B, C, E
Rationale: The correct interventions for the client with chemotherapy-induced nausea are B, C, and E.
B: Providing sips of room temperature ginger ale can help alleviate nausea due to its antiemetic properties.
C: Maintaining the head of the client's bed in an elevated position after eating can prevent acid reflux and reduce nausea.
E: Assisting the client in using guided imagery can help distract from nausea and promote relaxation.
Incorrect choices:
A: Using seasonings may exacerbate nausea in some clients.
D: Offering cold milk as a meal replacement may not be well-tolerated by a nauseated client and could worsen symptoms.
In summary, the correct interventions focus on soothing the stomach, promoting relaxation, and preventing exacerbation of nausea, while the incorrect choices may not directly address the client's symptoms or could potentially worsen them.
The partner of an older adult client who has Alzheimer's disease reports that he is not eating. The client's partner refuses to assist the client with feeding and insists the client feed himself without help. What is the priority action the nurse should take?
- A. Arrange for Meals on Wheels assistance
- B. Determine the client's ability to self-feed
- C. Direct the home health aide to assist with meals
- D. Refer the client's partner to an Alzheimer's support group
Correct Answer: B
Rationale: The correct answer is B: Determine the client's ability to self-feed. This is the priority action because it addresses the immediate concern of the client not eating due to the partner's refusal to assist. By assessing the client's ability to self-feed, the nurse can identify any barriers or challenges the client may be facing, such as physical limitations or cognitive impairments. This assessment will guide the nurse in developing an appropriate plan of care to ensure the client's nutritional needs are met.
The other choices are incorrect because they do not directly address the client's current situation.
A: Meals on Wheels assistance may be helpful but does not address the immediate need for the client to eat.
C: Directing the home health aide to assist assumes the client is willing to accept help, which may not be the case.
D: Referring the client's partner to an Alzheimer's support group is important for long-term support but does not address the immediate issue of the client not eating.