Nokea
A parish nurse is leading a support group for clients whose family members have committed suicide. Which of the following strategies should the nurse plan to use during the group session?
- A. Encourage clients to establish a timeline for their own grieving process.
- B. Initiate a discussion with clients about ways to cope with changes in family dynamics.
- C. Assist clients in identifying ways suicide could have been prevented.
- D. Discourage clients from sharing negative aspects of their relationship with the deceased persons.
Correct Answer: B
Rationale: The correct answer is B: Initiate a discussion with clients about ways to cope with changes in family dynamics. This strategy is important in supporting clients dealing with the aftermath of a family member's suicide as it acknowledges the significant impact on family dynamics. It allows clients to explore and process the changes within the family system and develop coping mechanisms. This approach fosters open communication and mutual support within the group.
Choice A is incorrect because grief is a highly individualized process and establishing a timeline may not be helpful or realistic for everyone. Choice C is incorrect as it may inadvertently place blame on the deceased and lead to feelings of guilt among clients. Choice D is incorrect as it can hinder the healing process by suppressing valid emotions and preventing the group from exploring their feelings openly.
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A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?
- A. Contact
- B. Droplet
- C. Airborne
- D. Protective
Correct Answer: B
Rationale: The correct answer is B: Droplet precautions. Pharyngeal diphtheria is primarily spread through respiratory droplets when an infected person coughs or sneezes. Droplet precautions involve wearing a mask and eye protection within 3 feet of the patient to prevent the transmission of respiratory secretions. Contact precautions (Choice A) are for diseases transmitted through direct contact with the patient or contaminated surfaces. Airborne precautions (Choice C) are for diseases spread through tiny particles that can remain suspended in the air for long periods. Protective precautions (Choice D) are not a standard precaution type.
A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who is ambulatory and receiving oxygen
- B. A client who has a fracture and is in balance suspension traction
- C. A client who is bedridden and wears a hearing aid
- D. A client who uses a wheelchair and is confused
Correct Answer: A
Rationale: The correct answer is A: A client who is ambulatory and receiving oxygen should be evacuated first during a fire. This client has the highest risk due to the combination of mobility impairment and oxygen use, which increases the potential for rapid deterioration in a fire emergency. Oxygen supports combustion, making this client more vulnerable to fire-related injuries.
Choice B: A client with a fracture in balance suspension traction is stable and can wait for evacuation. Choice C: A bedridden client with a hearing aid can still hear evacuation instructions and wait for assistance. Choice D: A confused client in a wheelchair may require assistance but is not at immediate risk like the ambulatory client with oxygen.
A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify her religious preferences?
- A. Do you receive Holy Communion?
- B. Do you follow a kosher diet?
- C. Do you consume pork products?
- D. Do you oppose receiving a blood transfusion if necessary?
Correct Answer: C
Rationale: The correct answer is C: Do you consume pork products? This question is relevant for a client practicing Islam as pork consumption is prohibited in Islam. Asking about pork consumption helps the nurse understand and respect the client's religious beliefs.
Incorrect answers:
A: Do you receive Holy Communion? - This question is related to Christian practices, not Islam.
B: Do you follow a kosher diet? - This question is related to Jewish dietary laws, not specific to Islam.
D: Do you oppose receiving a blood transfusion if necessary? - While some religious beliefs may affect views on blood transfusions, this question does not specifically address Islamic beliefs.
A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?
- A. Sacrum
- B. Palms of the hands
- C. Shoulders
- D. Area of trauma
Correct Answer: B
Rationale: The nurse should observe the palms of the hands to assess for cyanosis in a client with dark skin because this area is less pigmented and cyanosis is easier to detect. Palms have thinner skin and blood vessels are closer to the surface, making it more likely to show changes in color due to decreased oxygen levels. The sacrum, shoulders, and areas of trauma may not accurately reflect cyanosis in dark-skinned individuals due to the differences in skin pigmentation and thickness. By focusing on the palms, the nurse can accurately assess for cyanosis and provide appropriate care.
A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?
- A. Hypertension
- B. Fibromyalgia
- C. Renal calculi
- D. Fibrocystic breast disease.
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Hypertension is a contraindication to combination oral contraceptive use due to the increased risk of cardiovascular events. The estrogen component in oral contraceptives can further elevate blood pressure, leading to complications. Other choices like B: Fibromyalgia, C: Renal calculi, and D: Fibrocystic breast disease are not contraindications for oral contraceptive use. Fibromyalgia is a chronic pain condition unrelated to oral contraceptives. Renal calculi are kidney stones, which do not directly affect the safety of oral contraceptives. Fibrocystic breast disease is a benign condition and not a contraindication to oral contraceptives.