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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 person
Correct Answer: B
Rationale: The correct answer is B: Initiate a discussion with clients about ways to cope with changes in family dynamics. This is the most appropriate strategy as it addresses the immediate impact of the suicide on family dynamics and helps clients develop coping mechanisms. Discussing coping strategies can empower clients to navigate the difficult changes they are facing.
A: Encouraging clients to establish a timeline for their own grieving process may not be helpful as each individual grieves differently and timelines can vary significantly.
C: Assisting clients in identifying ways suicide could have been prevented may lead to feelings of guilt and self-blame, which can be harmful to the healing process.
D: Discouraging clients from sharing negative aspects of their relationship with the deceased person can hinder the expression of emotions and the processing of complex feelings related to the loss.
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Which of the following findings places the client at risk if he receives alteplase?
- A. Family history of malignant hypertension
- B. Hip arthroplasty 1 week ago
- C. Chronic obstructive pulmonary disease
- D. Acute renal failure 6 months ago
Correct Answer: B
Rationale: Recent surgeries increase bleeding risks with thrombolytics.
Which of the following actions should the nurse take?
- A. Administer a bronchodilator after the procedure
- B. Perform the procedure prior to meals.
- C. Perform the procedure twice each day.
- D. Hold hand flat to perform percussions on the child
Correct Answer: B
Rationale: Postural drainage should be done before meals to prevent nausea and vomiting.
A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take?
- A. Administer oral acetaminophen.
- B. Cover the adolescent with a thermal blanket
- C. Submerge the adolescent's feet in ice water
- D. Initiate seizure precautions.
Correct Answer: D
Rationale: The correct answer is D: Initiate seizure precautions. Hyperthermia can lead to seizures due to the brain's sensitivity to high temperatures. Seizure precautions involve ensuring a safe environment, padding the bed, and having emergency equipment ready. Administering oral acetaminophen (A) is not the priority in hyperthermia as it may not rapidly reduce the temperature. Covering with a thermal blanket (B) may further increase body temperature. Submerging feet in ice water (C) can cause vasoconstriction and shivering, leading to increased core temperature.
A nurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following actions should the nurse take?
- A. Use leading statements to obtain information from the child
- B. Ensure that multiple nurses are present for the physical examination
- C. Explain to the child what will happen when the abuse is reported
- D. Reassure the child that no one will be told about the abuse
Correct Answer: C
Rationale: Correct Answer: C - Explain to the child what will happen when the abuse is reported.
Rationale: It is crucial for the nurse to inform the child about the reporting process to ensure transparency and build trust. This empowers the child and helps them understand the next steps. It also promotes their involvement in decision-making regarding their well-being. By explaining the process, the nurse can offer emotional support and reassurance to the child. This approach respects the child's autonomy and dignity.
Incorrect Choices:
A: Using leading statements can influence the child's responses and compromise the accuracy of information obtained.
B: Having multiple nurses present may intimidate the child and breach confidentiality.
D: Reassuring the child that no one will be told about the abuse may perpetuate feelings of isolation and hinder the necessary intervention.
Which of the following actions should the nurse take first?
- A. Determine the client's Glasgow Coma Scale score
- B. Insert an indwelling urinary catheter for the client.
- C. Administer mannitol IV bolus to the client
- D. Prepare the client for an MRI of the brain.
Correct Answer: A
Rationale: The correct answer is A: Determine the client's Glasgow Coma Scale (GCS) score. This is the priority action as it helps assess the client's level of consciousness and neurological status quickly. It guides further interventions and treatment decisions. Inserting an indwelling urinary catheter (B) or administering mannitol IV bolus (C) may be needed but assessing neurological status comes first. Preparing for an MRI (D) is important but not the initial step.