Nokea
A school nurse is approached by a student who says that her friend has been cutting herself on the arms. The student asks the nurse not to tell anyone. Which response by the nurse is correct?
- A. I have to notify her parents, because this affects her personal safety.
- B. I won't tell anyone, but let me know if she starts talking about suicide.
- C. I will call the hospital and let them send a psychiatrist to do an evaluation on your friend.
- D. I will make it a point to run into her in the hall and notice the cuts on her arms so I can ask about them.
Correct Answer: A
Rationale: Self-harm indicates a safety risk, requiring parental notification to ensure the student receives appropriate intervention.
You may also like to solve these questions
The nurse is assisting a client with a colostomy irrigation. The client is positioned on the toilet and has removed the colostomy pouch, and the irrigation bag is filled with 1000 mL of warm water. Place the following actions (in Roman numerals) in the correct order from first to last
- A. Allow 15 to 20 minutes for evacuation and then fold the sleeve, secure it, and leave it in place for 30 to 45 minutes before removing it.
- B. Allow the solution to flow in for 5 to 10 minutes and then clamp the tubing and close the top of the irrigation sleeve.
- C. Apply gloves, lubricate the cone tip, and insert it into the stoma, holding it securely.
- D. Apply the irrigation sleeve over the stoma.
- E. Hang the irrigation solution with the bottom of the bag being 20 inches above the stoma.
Correct Answer: E,D,C,B,A
Rationale: The correct order is: Hang the irrigation solution (V), apply the irrigation sleeve (IV), insert the cone tip (III), allow solution to flow (II), and allow evacuation (I), ensuring proper setup and procedure.
Which of the following observations best indicates to the nurse that a paraplegic client can adequately carry out activities of daily living at home after discharge?
- A. The client can shave himself and brush his teeth.
- B. The client can transfer himself into and out of his wheelchair.
- C. The client can maneuver his wheelchair without difficulty.
- D. The client can prepare his own well-balanced meals.
Correct Answer: B
Rationale: essential if client is to perform ADLs
The nurse is preparing to transfer a client from the ED to the orthopedic unit. She knows that adhering to the hospital policy for client handoffs best ensures which of the following?
- A. privacy
- B. Patient's Bill of Rights
- C. continuity of care
- D. case management
Correct Answer: C
Rationale: Proper handoffs ensure continuity of care by transferring critical information accurately between care teams.
A client with a head injury has an intracranial pressure (ICP) monitor in place. Cerebral perfusion pressure calculations are ordered. If the client's ICP is 22 and the mean pressure reading is 70, what is the client's cerebral perfusion pressure?
- A. 92
- B. 72
- C. 58
- D. 48
Correct Answer: D
Rationale: Cerebral perfusion pressure (CPP) = Mean Arterial Pressure (MAP) - ICP. Given MAP = 70 and ICP = 22, CPP = 70 - 22 = 48. Thus, the answer is 48.
The client with a pacemaker should be taught to:
- A. Report ankle edema
- B. Check his blood pressure daily
- C. Refrain from using a microwave oven
- D. Monitor his pulse rate
Correct Answer: D
Rationale: Monitoring pulse rate ensures the pacemaker is functioning correctly and detects arrhythmias.