Nokea
A nurse working at the clinic is teaching a group of clients who are pregnant on the use of nonpharmacological pain management. Which of the following is an appropriate description of the use of hypnosis during labor?
- A. Hypnosis focuses on biofeedback as a relaxation technique
- B. Hypnosis promotes increased control of pain perception during contractions
- C. Hypnosis uses therapeutic touch to reduce anxiety during labor
- D. Hypnosis provides instruction to minimize pain
Correct Answer: B
Rationale: The correct answer is B. Hypnosis during labor helps the client gain increased control over her perception of pain, allowing for better pain management during contractions. Choice A is incorrect because hypnosis and biofeedback are distinct techniques. Choice C is incorrect as therapeutic touch and hypnosis are different modalities. Choice D is incorrect as hypnosis does not simply provide instruction to minimize pain, but rather helps the individual control their perception of pain.
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A nurse is assisting with mass casualty triage following an explosion at a local factory. Which of the following clients should the nurse identify as the priority?
- A. A client who has massive head trauma
- B. A client who has full-thickness burns to the face and trunk
- C. A client with indications of hypovolemic shock
- D. A client with an open fracture of the lower extremity
Correct Answer: C
Rationale: In a mass casualty situation, the nurse should prioritize the client with indications of hypovolemic shock. Hypovolemic shock is an immediate life-threatening condition resulting from severe blood loss, which can lead to organ failure and death. Prompt identification and treatment of hypovolemic shock are crucial to prevent further deterioration. While clients with massive head trauma, full-thickness burns, and open fractures require urgent care, hypovolemic shock takes precedence due to its rapid progression to a critical state.
A charge nurse is evaluating the time management skills of a newly licensed nurse. The charge nurse should intervene when the newly licensed nurse does which of the following?
- A. Re-evaluates priorities halfway through the shift
- B. Delegates changing a sterile dressing to a licensed practical nurse
- C. Groups activities for the same client
- D. Works on several tasks simultaneously
Correct Answer: D
Rationale: The correct answer is D. Working on several tasks simultaneously may lead to errors due to divided attention and lack of focus. It is important for nurses to prioritize tasks and complete them one at a time to ensure thoroughness and accuracy. Choices A, B, and C are appropriate time management strategies. Re-evaluating priorities, delegating tasks appropriately, and grouping activities for the same client can help improve efficiency and quality of care.
A nurse is caring for a client in the second trimester of pregnancy and asks how to treat constipation. Which of the following statements by the nurse is appropriate?
- A. Decrease intake of vitamins and supplements to every other day
- B. Eat 15 g of fiber per day
- C. Consume 48 ounces of water each day
- D. Drink hot water with lemon juice each morning
Correct Answer: D
Rationale: The correct answer is D. Drinking hot water with lemon juice in the morning is a natural and safe way to stimulate bowel movements and relieve constipation during pregnancy. Option A is incorrect as vitamins and supplements should not be decreased without consulting a healthcare provider, especially during pregnancy. Option B is inadequate as the recommended daily fiber intake during pregnancy is higher than 15g. Option C, while important for overall health, does not directly address constipation relief in pregnancy.
A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority to report to the provider?
- A. Constipation
- B. Blurred vision
- C. Fever
- D. Dry mouth
Correct Answer: C
Rationale: The correct answer is C: Fever. Clozapine can cause agranulocytosis, a serious condition that leads to infections. Fever may indicate an underlying infection, a potentially life-threatening complication, and must be reported immediately to the provider for further evaluation and management.
Choice A (Constipation) is a common side effect of clozapine but is not as urgent as fever. Blurred vision (Choice B) and dry mouth (Choice D) are side effects of clozapine but are not indicative of a life-threatening condition like agranulocytosis.
A nurse is planning care for a newly admitted adolescent client who has bacterial meningitis. Which of the following instructions is appropriate for the nurse to include in the plan of care?
- A. Initiate droplet precautions
- B. Assist the client to a supine position
- C. Perform Glasgow Coma Scale assessment every 24 hours
- D. Recommend prophylactic acyclovir for the client's family
Correct Answer: A
Rationale: The correct answer is A: 'Initiate droplet precautions.' Bacterial meningitis requires droplet precautions to prevent the spread of infection, as the bacteria can be transmitted through respiratory secretions. Choice B is incorrect because assisting the client to a supine position is not specific to the care of a client with bacterial meningitis and may not be appropriate for all clients. Choice C is incorrect because while performing Glasgow Coma Scale assessments is important in managing clients with neurological conditions, it is not directly related to preventing the spread of bacterial meningitis. Choice D is incorrect because recommending prophylactic acyclovir for the client's family is not a standard precautionary measure for preventing the spread of bacterial meningitis.