Nokea
A primary concern of the hospitalized adolescent is:
- A. Respect for the need for privacy.
- B. Allowing parents to visit after hours.
- C. Wearing a hospital gown.
- D. The fear of loss of control when in pain.
Correct Answer: A
Rationale: Adolescents value autonomy and privacy, which is a primary concern during hospitalization, as it supports their developmental need for independence.
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The nurse is planning discharge care with the parents of a 16-year-old boy who recently attempted suicide. The nurse should advise the parents to tell the nurse if their son:
- A. Expresses a desire to date.
- B. Decides to try out for an extracurricular activity.
- C. Gives away valued personal items.
- D. Desires to spend more time with his friends.
Correct Answer: C
Rationale: Giving away valued items is a warning sign of suicidal intent, requiring immediate reporting. The other behaviors are normal adolescent activities.
The nurse manager is developing a 'read-back' procedure to reduce medication administration errors. Which of the following are purposes of the 'read-back' requirement? Select all that apply.
- A. To prohibit orders and test results from being communicated verbally or by telephone.
- B. To ensure that orders and test results that are communicated verbally or by telephone are clear to the receiver of the information.
- C. To make sure that orders and test results that are communicated verbally or by telephone are confirmed by the individual giving the information.
- D. To minimize the risk of non-authorized personnel from giving orders which are communicated verbally or by telephone.
- E. To encourage the use of electronic medical records.
Correct Answer: B,C,D
Rationale: Read-back ensures clarity, confirmation, and authorized communication of verbal orders, reducing errors. It does not prohibit verbal orders or mandate electronic records.
The nurse is counseling a client about the prevention of coronary heart disease. Which of the following vitamins should the nurse recommend the client include in his diet to reduce homocysteine levels? Select all that apply.
- A. Vitamin K.
- B. Vitamin B6.
- C. Folate.
- D. Vitamin B12.
- E. Vitamin D.
Correct Answer: B, C, D
Rationale: Vitamin B6, folate, and vitamin B12 reduce homocysteine levels, a risk factor for coronary heart disease.
The nurse evaluates the arterial blood gas (ABG) results of a client who is receiving supplemental oxygen. Which Po2 finding would indicate that the oxygen level was adequate?
- A. 45 mm Hg
- B. 50 mm Hg
- C. 60 mm Hg
- D. 80 mm Hg
Correct Answer: D
Rationale: The normal Po2 level is 80 to 100 mm Hg. The remaining options are low values and do not indicate adequate oxygen levels.
Which of the following is appropriate for a client with metabolic alkalosis?
- A. Monitor serum potassium levels
- B. Maintain the client on bed rest
- C. Have the client inhale carbon dioxide using a paper bag
- D. Administer sodium bicarbonate as ordered
Correct Answer: A
Rationale: Metabolic alkalosis can cause hypokalemia, so monitoring serum potassium levels is appropriate. Bed rest is not indicated, inhaling CO2 is for respiratory alkalosis, and sodium bicarbonate would worsen alkalosis.