Nokea
A nursing advocate is one who:
- A. makes decisions for others.
- B. encourages persons to make decisions for themselves and acts with or on behalf of the person to support those decisions.
- C. manages the care of others.
- D. is the legal representative for a person.
Correct Answer: B
Rationale: Nurse advocates work with clients to provide information and assistance is decision-making. The decisions and care that occur from these decisions are based on the right of the client to self-determination.
You may also like to solve these questions
A client is admitted for removal of a goiter. Which nursing intervention should receive priority during the post-operative period?
- A. Maintaining fluid and electrolyte balance
- B. Assessing the client's airway
- C. Providing needed nutrition and fluids
- D. Providing pain relief with narcotic analgesics
Correct Answer: B
Rationale: A goiter is hyperplasia of the thyroid gland. Removal of a goiter can result in laryngeal spasms and airway occlusion. The other answers are lesser in priority.
The family of an 88-year-old woman who was admitted with severe dehydration says to the nurse, 'Why don't you just tie down her arms so she won't try to get out her IV?' What is the best response for the nurse to make?
- A. Ask the physician for an order to restrain the woman
- B. Explain to the family that restraints are not allowed in the hospital unless the doctor orders them
- C. Assess the client's mental status and safety needs
- D. Tell the family that they can restrain the client, but the nurse cannot
Correct Answer: C
Rationale: Assessing mental status and safety needs determines if restraints are necessary, prioritizing least restrictive measures.
The nurse is caring for a client with increased intracranial pressure (ICP). Which statement by the unlicensed assistive personnel would require immediate intervention by the nurse?
- A. I will raise the head of the bed so it is easier to see the television.
- B. I will turn down the lights when I leave.
- C. Let me move your belongings closer so you can reach them
- D. You should do deep breathing and coughing exercises.
Correct Answer: A
Rationale: Raising the head of the bed (A) without medical guidance can alter ICP dangerously. Dimming lights (B), moving belongings (C), and breathing exercises (D) are generally safe or neutral.
Which of the following situations is most likely to produce sepsis in the neonate?
- A. Maternal diabetes
- B. Prolonged rupture of membranes
- C. Cesarean delivery
- D. Precipitous vaginal birth
Correct Answer: B
Rationale: Prolonged rupture of membranes. Premature rupture of the membranes (PROM) is a leading cause of newborn sepsis. After 12-24 hours of leaking fluid, measures are taken to reduce the risk to mother and the fetus/newborn.
A home health nurse is visiting a client with chronic heart failure. The nurse observes that the client is having trouble answering questions due to breathlessness and cough. Which action should the nurse take first?
- A. Auscultate breath sounds
- B. Check for peripheral edema
- C. Measure the client's vital signs
- D. Review the client's weight log over the past several days
Correct Answer: A
Rationale: Auscultating breath sounds (A) assesses the cause of breathlessness (e.g., pulmonary edema) in heart failure, guiding immediate interventions. Edema (B), vitals (C), and weight (D) are secondary.