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A nurse is using the NURSE mnemonic when speaking with a client who is experiencing grief. The client reports that they are feeling overwhelmed. Which of the following responses by the nurse demonstrates the 'E' in the NURSE mnemonic?
- A. It sounds like you are exhausted
- B. You have so much to deal with, how can I be of help to you?
- C. Tell me more about how you are feeling
- D. It is impressive how you have managed to deal with this situation
Correct Answer: A
Rationale: The correct answer is A. In the NURSE mnemonic, 'E' stands for empathy. By acknowledging the client's feeling of being overwhelmed and reflecting it back by saying "It sounds like you are exhausted," the nurse demonstrates empathy. This response shows understanding and validation of the client's emotions, which can help the client feel heard and supported.
Choice B focuses more on offering help without directly addressing the client's emotional state. Choice C is about exploring the client's feelings but does not directly acknowledge the expressed emotion of being overwhelmed. Choice D praises the client's coping skills but does not address the current emotional state of feeling overwhelmed.
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A nurse is preparing to lift a heavy object. Which of the following actions by the nurse indicates understanding of body mechanics?
- A. They bend at the hip when lifting
- B. They keep their feet together when lifting an object
- C. They stand close to the object being moved
- D. They twist their spine when lifting
Correct Answer: C
Rationale: The correct answer is C: They stand close to the object being moved. This action indicates understanding of body mechanics as it reduces the strain on the back by keeping the load close to the body's center of gravity. Standing close to the object allows for better leverage and control during the lift, minimizing the risk of injury.
Rationale for why other choices are incorrect:
A: Bending at the hip when lifting can put excessive strain on the lower back.
B: Keeping feet together may lead to instability and lack of balance during lifting.
D: Twisting the spine when lifting can result in spinal injuries and muscle strain.
A nurse is caring for a client whose partner died 3 years ago and reports that they are still unable to accept the loss. The nurse should identify that the client has manifestations of which of the following types of grief?
- A. Uncomplicated grief
- B. Prolonged grief
- C. Anticipatory grief
- D. Disenfranchised grief
Correct Answer: B
Rationale: The correct answer is B: Prolonged grief. This is because the client is still struggling to accept the loss after 3 years, which is indicative of prolonged grief. Uncomplicated grief (Choice A) typically resolves within a reasonable timeframe. Anticipatory grief (Choice C) occurs before the actual loss. Disenfranchised grief (Choice D) is when the individual's grief is not openly acknowledged or socially supported. In this scenario, the client's grief extends beyond the normal grieving process, indicating prolonged grief.
A nurse is teaching a newly licensed nurse about preventing puncture injuries. Which of the following instructions should the nurse include?
- A. Break needles on syringes before disposal
- B. Use two hands to recap a needle after administering a medication
- C. Dispose of used razors in wastebaskets
- D. Replace sharps containers when they are 3/4 full
Correct Answer: D
Rationale: The correct answer is D: Replace sharps containers when they are 3/4 full. This instruction is crucial in preventing puncture injuries as overfilling sharps containers can increase the risk of accidental needle sticks. By replacing the containers when they are 3/4 full, it ensures that there is enough space to safely dispose of needles and other sharp objects without risking spills or injuries.
Explanation of other choices:
A: Breaking needles on syringes before disposal is unsafe as it can increase the risk of needle stick injuries.
B: Using two hands to recap a needle is dangerous and not recommended as it can lead to accidental needle sticks.
C: Disposing of used razors in wastebaskets is improper as they should be disposed of in puncture-proof containers.
Summary: Option D is the correct choice as it emphasizes safe disposal practices to prevent puncture injuries, while the other options promote unsafe practices that can increase the risk of needle stick injuries.
A nurse is admitting a new client. Which of the following steps of the nursing process is the nurse performing when formulating goals to address an identified problem?
- A. Planning
- B. Implementation
- C. Assessment
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Planning. In the nursing process, planning involves formulating goals and developing a plan of action to address the identified problems from the assessment phase. During this step, the nurse sets specific, measurable, achievable, relevant, and time-bound (SMART) goals to guide the care provided. Planning ensures that interventions are tailored to the client's unique needs and helps achieve positive outcomes. The other choices are incorrect because: B: Implementation involves carrying out the plan, C: Assessment is the initial step of gathering data, and D: Evaluation is the final step to determine the effectiveness of the interventions.
A nurse on a medical unit is reviewing the laboratory reports for a client. Which of the following laboratory values is the priority to report to the provider?
- A. Potassium level 3 mEq/L
- B. BUN 9.5 mg/dL
- C. Creatinine 0.4 mg/dL
- D. Sodium 135 mEq/L
Correct Answer: A
Rationale: The correct answer is A: Potassium level 3 mEq/L. A potassium level of 3 mEq/L is below the normal range (3.5-5.0 mEq/L), indicating hypokalemia. Hypokalemia can lead to serious cardiac arrhythmias. Therefore, it is crucial to report this abnormal potassium level promptly to the provider for further evaluation and intervention.
B: BUN 9.5 mg/dL - This is within the normal range (7-20 mg/dL) and does not require immediate intervention.
C: Creatinine 0.4 mg/dL - This is within the normal range (0.6-1.2 mg/dL) and does not indicate an urgent issue.
D: Sodium 135 mEq/L - This is within the normal range (135-145 mEq/L) and does not require immediate action.