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A parish nurse is counseling a family following a client's recent diagnosis of heart disease. Which of the following actions should the nurse take first?
- A. Discuss the benefits of eating a well-balanced diet with the client's family
- B. Assist the client and the client's partner with finding an affordable exercise program
- C. Offer to accompany the client and the client's partner during health care provider visits
- D. Ask family members about the impact of the disease on relationships within the family
Correct Answer: D
Rationale: The correct answer is D: Ask family members about the impact of the disease on relationships within the family. This is the first action the nurse should take because understanding the family dynamics and relationships can provide valuable insight into how the diagnosis is affecting everyone involved. By assessing the impact on relationships, the nurse can better tailor interventions to support the entire family unit and address any emotional or communication challenges that may arise.
Option A is incorrect as discussing diet benefits should come after assessing the family dynamics. Option B is incorrect because addressing exercise programs should also come after understanding the family's needs. Option C is incorrect as accompanying to provider visits is important but not the first priority.
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Which of the following statements should the nurse include in teaching about meningococcal meningitis?
- A. Toothbrush should be placed beside the child's bed
- B. Household contacts will receive prophylactic antibiotics
- C. Transmission will be prevented because of herd immunity
- D. The child is most contagious after the rash develops
Correct Answer: B
Rationale: The correct answer is B: Household contacts will receive prophylactic antibiotics. This statement should be included in teaching about meningococcal meningitis because prophylactic antibiotics are recommended for close contacts to prevent the spread of the infection. This is crucial in preventing outbreaks and protecting others who may have been exposed.
A: Placing a toothbrush beside the child's bed is not relevant to preventing the spread of meningococcal meningitis.
C: Transmission prevention through herd immunity is not a reliable method for controlling the spread of meningococcal meningitis.
D: The child is most contagious before the rash develops, not after, making this statement incorrect.
In summary, teaching about prophylactic antibiotics for household contacts is essential in managing meningococcal meningitis, while the other options do not directly address prevention measures.
A home health nurse is assessing a client who has AIDS. Which of the following responses by the client indicates a risk for suicide?
- A. I'm afraid of experiencing pain near the end.
- B. I know that everything will be better soon.
- C. I am relying more and more on my partner for support.
- D. I don't want to lose control of my ability to make decisions.
Correct Answer: B
Rationale: The correct answer is B: "I know that everything will be better soon." This response indicates a risk for suicide as it reflects a sense of hopelessness or feeling that things will not improve. This mindset is often associated with suicidal ideation.
A: Fear of pain near the end is a common concern in terminal illnesses but does not directly indicate suicide risk.
C: Relying on a partner for support can be a coping mechanism and does not necessarily indicate suicide risk.
D: Desire to maintain decision-making control is a sign of autonomy and does not directly indicate suicide risk.
In summary, choice B is correct as it suggests a lack of hope for the future, while the other choices do not directly indicate a risk for suicide.
A client states, 'My life has no meaning right now.' What is the nurse's best response?
- A. Have you been thinking about harming yourself?
- B. How long have you been feeling this way?
- C. Tell me what is going on with you right now.
- D. Do you really think your life has no purpose?
Correct Answer: A
Rationale: The correct answer is A. By asking the client if they have been thinking about harming themselves, the nurse is directly addressing the potential risk of suicide, which is crucial when a client expresses feelings of hopelessness. This question helps assess the client's safety and determine the need for immediate intervention. Choices B, C, and D are not as direct in addressing the potential risk of self-harm and may not provide the necessary urgency in ensuring the client's safety. Asking about self-harm is critical in assessing the severity of the client's distress and ensuring appropriate interventions are implemented promptly.
A community health nurse is caring for a client in a culturally diverse community. Which of the following actions demonstrates accurate cultural knowledge about a specific cultural group?
- A. Touching the hair of an African American client during an assessment
- B. Offering to shake hands when meeting an Asian client of the opposite gender
- C. Maintaining eye contact when interviewing a Native American client
- D. Including both hot and cold food items from a Hispanic client's menu
Correct Answer: D
Rationale: The correct answer is D because it shows respect for the Hispanic client's cultural dietary preferences. In Hispanic culture, hot and cold foods are believed to have different properties that can affect health. By including both options on the menu, the nurse demonstrates understanding and acceptance of this cultural belief. Touching the hair of an African American client (A) can be considered intrusive and disrespectful. Offering to shake hands with an Asian client of the opposite gender (B) may not be culturally appropriate in some Asian cultures due to gender norms. Maintaining eye contact with a Native American client (C) may be perceived as disrespectful as some Native American cultures view direct eye contact as confrontational.
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.