Nokea
An adolescent is preparing to return home after psychiatric hospitalization for a suicide attempt. Which actions would be most effective to support family processes when the client returns home?
- A. Make a video of the ride home in the car.
- B. Identify the family's strengths and weaknesses.
- C. Ask that the mother's boyfriend move out of the home.
- D. Provide and offer the family appropriate options and resources.
- E. Encourage communication and the sharing of feelings among the family members.
Correct Answer: B,D,E
Rationale: After the crisis time of a family member's suicide attempt, safety for the recovering individual is a priority. Families can provide support and encouragement in a caring home environment. Options 2, 4, and 5 offer helpful ways to enhance the family processes. Options 1 and 3 are clearly the least effective options because there is no information in the question that indicates that these actions are relative to the suicide attempt.
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The nurse is planning care for a client who presents in active labor with a history of a previous cesarean delivery. The client complains of a 'tearing' sensation in the lower abdomen. She is upset, and she expresses concern for the safety of her baby. Which therapeutic response to the nurse make?
- A. Try not to worry, you and your baby are in good hands.'
- B. I understand your concerns. I'll let your health care provider know you need to talk.'
- C. I don't have time to answer questions now but I'll plan for us to have time to talk later.'
- D. I can understand that you are fearful. We are doing everything possible for your baby.'
Correct Answer: D
Rationale: Clients have a concern for the safety of their baby during labor and delivery, especially when a problem arises. Empathy and a calm attitude with realistic reassurances are important aspects of client care. Dismissing or ignoring the client's concerns can lead to increased fear and a lack of cooperation. Option 1 uses a cliché and provides false reassurance. Options 2 and 3 place the client's feelings on hold.
A 79-year-old client with moderate dementia and limited mobility is being cared for at home by her son who lives with her. She has been receiving home health for care of a nonhealing diabetic foot ulcer. The home health nurse encourages the son to bring his mother to the ED for more aggressive treatment in an in-patient setting. The son responds that he cannot afford to pay for the medical bills and prefers to care for her at home. The nurse then notices a stage 2 decubitus ulcer on the client's sacrum. The son claims to have his sister come every day and assist with bathing and turning in the bed. Which type of violence is the son guilty of?
- A. physical neglect
- B. physical violence
- C. emotional violence
- D. economic exploitation
Correct Answer: A
Rationale: Physical neglect involves failing to provide adequate care, such as preventing pressure ulcers through proper turning, leading to conditions like the stage 2 decubitus ulcer.
An older client is admitted to the hospital with a fractured hip and is experiencing periods of confusion. The nurse develops a plan of care and should identify which psychosocial outcome as having the greatest impact on improving the client's cognitive abilities?
- A. Improved sleep patterns
- B. Reduced family fears and anxiety
- C. Meeting self-care needs independently
- D. Increased ability to concentrate and participate in care
Correct Answer: D
Rationale: The client needs to be able to concentrate and participate in her or his care. When the client is able to do that, the nurse can work with the client to achieve the other outcomes. Options 1 and 3 address physiological needs rather than psychosocial outcomes. Option 2 is a secondary need and does not address the client.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?
- A. Apply a warm compress proximal to the site.
- B. Check for kinks in the tubing and raise the IV pole.
- C. Adjust the tape that stabilizes the needle.
- D. Flush with normal saline and recount the drop rate.
Correct Answer: B
Rationale: When encountering a slowed peripheral IV rate, the nurse should initially check for common factors affecting infusion rates. Factors such as the height of the IV bag, presence of kinks in the tubing, needle size or position, client blood pressure, fluid viscosity, and infiltration can impact the rate. It is crucial to ensure the tubing is free of any kinks and that the IV pole is at an appropriate height to facilitate proper flow by gravity. Applying warmth proximal to the site might help with venospasm, but this intervention should come after ensuring proper tubing flow. Adjusting the tape that stabilizes the needle or flushing with normal saline may be necessary later in the troubleshooting process, but these actions should follow checking for kinks and adjusting the IV pole height, which are less invasive interventions.
A client scheduled for pulmonary angiography is fearful about the procedure and asks the nurse if the procedure involves significant pain and radiation exposure. Which therapeutic response should the nurse make to the client to provide reassurance?
- A. The procedure is somewhat painful, but there is minimal exposure to radiation.'
- B. Discomfort may occur with needle insertion, and there is minimal exposure to radiation.'
- C. There is very mild pain throughout the procedure, and the exposure to radiation is negligible.'
- D. There is usually no pain, although a moderate amount of radiation must be used to get accurate results.'
Correct Answer: B
Rationale: Pulmonary angiography involves minimal exposure to radiation. The procedure is painless, although the client may feel discomfort with insertion of the needle for the catheter that is used for dye injection. This information supports the fact that the other options are incorrect.