Nokea
When encountering the significant other of a patient with end-stage AIDS crying during her smoke break, what is the most appropriate action for the nurse to take?
- A. Allow her to grieve by herself.
- B. Tell her to go ahead and cry, after all, your husband’s pretty bad off.
- C. Tell her you realize how upset she is, but you don’t want to talk about it now.
- D. Approach her, offering tissues, and encourage her to verbalize her feelings
Correct Answer: D
Rationale: Approaching the significant other, offering tissues, and encouraging her to verbalize her feelings is the most appropriate action for the nurse to take. Being left alone during the grief process isolates individuals, and they need an outlet for their feelings. By showing empathy and providing support, the nurse can help the significant other cope with her emotions. Choices A, B, and C are inappropriate because they do not offer support or encourage the expression of feelings, which are crucial in such situations.
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A healthcare provider is caring for a patient who has experienced burns to the right lower extremity. According to the Rule of Nines, which of the following percentages most accurately describes the severity of the injury?
- A. 36%
- B. 27%
- C. 18%
- D. 9%
Correct Answer: C
Rationale: According to the Rule of Nines, the right lower extremity accounts for 18% of the total body surface area. The Rule of Nines divides the body into regions, each representing 9% or a multiple of 9%, allowing for a quick estimation of the extent of burns. In this case, the correct answer is 18% as it corresponds to the percentage allocated for each lower extremity. Choices A, B, and D are incorrect as they do not match the standard allocation for the right lower extremity in the Rule of Nines.
Which of the following situations requires nurse intervention?
- A. A certified nursing assistant states, 'The patient in 307 is not wearing gloves while shaving her legs.'
- B. A nursing assistant at the nursing station states, 'The patient in 307 has a respiratory rate of 16.'
- C. A nursing student in the cafeteria states, 'Dr. Jones told the patient in room 307 that she was going to die.'
- D. A certified nursing assistant states, 'Dr. Jones hasn't made rounds this morning.'
Correct Answer: C
Rationale: The correct answer is C. Patient confidentiality must be maintained at all times to respect the patient's privacy and dignity. Disclosing sensitive information like a patient's prognosis in a public setting violates confidentiality and can cause distress. The nurse should intervene in this situation and educate the nursing student about the importance of not discussing confidential patient information in public. Choices A, B, and D do not involve breaching patient confidentiality and do not require immediate nurse intervention. Choice A focuses on infection control measures, choice B relates to clinical assessment, and choice D is about the doctor's rounds, which are not urgent matters requiring immediate intervention.
Which of the following is not typically considered one of the main mechanisms of Type II Diabetes treatment?
- A. Medications
- B. Nutrition
- C. Increased activity
- D. Continuous Insulin
Correct Answer: D
Rationale: Continuous Insulin is not typically considered one of the main mechanisms for treating Type II Diabetes. While medications, nutrition, and increased activity play crucial roles in managing Type II Diabetes, continuous insulin therapy is more common in Type I Diabetes or in specific cases of Type II Diabetes where other treatments are ineffective. Therefore, the correct answer is Continuous Insulin. Choices A, B, and C are mainstays in the treatment of Type II Diabetes, making them incorrect answers.
A mother brings her 13-month-old child with Down Syndrome to a pediatric clinic reporting muscle weakness and poor movement. The child's reflexes are noted to be diminished. Which action should the nurse take first?
- A. Contact the physician immediately
- B. Have the patient go for an X-ray for a c-spine work-up
- C. Start an IV on the patient
- D. Position the child's neck in a neutral position
Correct Answer: D
Rationale: In a child with Down Syndrome presenting with muscle weakness and diminished reflexes, an atlanto-axial dislocation is a concern. The priority action is to position the child's neck in a neutral c-spine posture to prevent further injury. This should be done before any movement or manipulation. Contacting the physician should follow to ensure appropriate evaluation and management. Initiating an IV is not indicated unless specifically ordered for a medical reason. Ordering an X-ray for a c-spine work-up should not be the first action as it may involve movement that could exacerbate the condition if an injury is present.
A nurse reviews the health history of a client who will be seeing the health care provider to obtain a prescription for a combination oral contraceptive (estrogen and progestin). Which finding in the health history would cause the nurse to determine that the use of a combination oral contraceptive is contraindicated?
- A. The client has type 2 diabetes mellitus.
- B. The client is being treated for hypertension.
- C. The client has been treated for breast cancer.
- D. The client has hyperlipidemia.
Correct Answer: C
Rationale: The correct answer is that the client has been treated for breast cancer. Combination oral contraceptives containing estrogen and progestin are contraindicated for women with a history of certain conditions, such as thrombophlebitis, thromboembolic disorders, cerebrovascular disease, coronary artery disease, myocardial infarction, known or suspected breast cancer, known or suspected estrogen-dependent neoplasm, benign or malignant liver tumors, and undiagnosed abnormal genital bleeding. Although having type 2 diabetes mellitus, being treated for hypertension, or having hyperlipidemia are risk factors that require caution when using combination oral contraceptives, they are not absolute contraindications like a history of breast cancer.