Nokea
Nurse counseling young adult who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention?
- A. "I have my own apt now
- B. but it's not easy living away from my parents."
- C. It's been so stressful for me to even think about having my own family.
- D. I don't even know who I am yet, & now I'm supposed to know what to do.
- E. My girlfriend is pregnant, & I don't think I have what it takes to be a good father.
Correct Answer: C
Rationale: The correct answer is C: "It's been so stressful for me to even think about having my own family." This is the priority issue as it indicates the young adult is struggling with the idea of starting a family, which can have long-term implications. This concern may affect their mental health, relationships, and decision-making. Option A is about independence, B about transitioning from parents, D about self-identity, and E about impending fatherhood. While important, these issues are not as urgent as the stress related to starting a family.
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Nurse caring for 5 yo whose parents report she fears painful procedures, like shots. Which strategies should nurse use to try to help ease child's fear? (Select all that apply.)
- A. Invite child to assist with mealtime activities
- B. Cluster invasive procedures whenever possible
- C. Assign caregivers with whom the child is familiar
- D. Have parents bring in favorite toy from home
- E. Engage child in pretend play with toy medical kit
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
A: Inviting the child to assist with mealtime activities can help build trust and rapport, making the child more comfortable and less fearful in the healthcare setting.
D: Having parents bring in the child's favorite toy from home can provide comfort and distraction, helping to alleviate fear and anxiety during procedures.
E: Engaging the child in pretend play with a toy medical kit allows for familiarization with medical tools in a non-threatening way, helping to reduce fear and anxiety related to medical procedures.
Summary:
B: Clustering invasive procedures may minimize the number of times the child needs to undergo such procedures but does not directly address the fear.
C: Assigning caregivers familiar to the child is important for comfort but may not directly address the fear of painful procedures.
Nurse is preparing a discharge summary for a client who had knee surgery and is going home. Which of the following info about the client should the nurse include in it? (Select all that apply.)
- A. Advance directives status
- B. Where to go for follow-up care
- C. Instructions for diet/meds
- D. Most recent vital sign data
- E. Contact info for home healthcare agency
Correct Answer: B,C,E
Rationale: The correct answers are B, C, and E.
B: Providing information on where to go for follow-up care ensures the client continues to receive proper medical attention post-surgery.
C: Instructions for diet/meds are crucial for the client's recovery and to prevent complications.
E: Providing contact info for a home healthcare agency ensures the client has access to additional support and care at home.
Incorrect answers:
A: Advance directives status is important but not directly related to immediate post-operative care.
D: Most recent vital sign data is important for monitoring but does not need to be included in a discharge summary.
Charge nurse is designating room assignments for clients. Based on her knowledge of fall prevention, which should be assigned to room closest to nursing station?
- A. 43 yo client post-op following laparoscopic cholecystectomy
- B. 61 yo client being admitted for telemetry to rule out MI
- C. 50 yo client post-op following open reduction internal fixation of ankle
- D. 79 yo client post-op following below-the-knee amputation
Correct Answer: D
Rationale: The correct answer is D. The 79 yo client post-op following below-the-knee amputation should be assigned to a room closest to the nursing station for fall prevention. This client may have mobility challenges, increased risk of falls due to recent surgery, and may require closer monitoring and immediate assistance if needed. Placing the client near the nursing station allows for quick response to any fall risk or postoperative complications.
A: The 43 yo client post-op following laparoscopic cholecystectomy is not at high risk for falls compared to the amputee.
B: The 61 yo client being admitted for telemetry to rule out MI does not necessarily have a higher fall risk than the amputee.
C: The 50 yo client post-op following open reduction internal fixation of ankle may have mobility limitations but is not as high risk for falls as the amputee.
Nurse is completing discharge teaching to client with COPD. Client verbalizes understanding of orthopneic position when he states, 'When I have difficulty breathing at night, I will...'
- A. Lie on my back with head & shoulders elevated on a pillow
- B. Lie flat on my stomach with head to one side
- C. Sit on side of my bed & rest my arms over pillows on top of my raised bedside table
- D. Lie on my side with my weight on my hips & shoulder with my arms flexed in front of me
Correct Answer: C
Rationale: The correct answer is C: Sit on side of my bed & rest my arms over pillows on top of my raised bedside table. Orthopneic position is sitting upright with arms supported, which helps improve lung expansion and ease breathing. Choice A is incorrect as lying on the back can worsen breathing difficulties. Choice B is incorrect as lying flat on the stomach hinders breathing. Choice D is incorrect as lying on the side does not provide the same lung expansion as sitting upright.
Nurse caring for a client who reports severe sore throat, pain with swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?
- A. Prodromal
- B. Incubation
- C. Convalescence
- D. Illness
Correct Answer: D
Rationale: The correct answer is D: Illness. In this stage, the client exhibits specific signs and symptoms of infection, such as severe sore throat, pain with swallowing, and swollen lymph nodes. This indicates active replication of the pathogen and the body's immune response. Other choices are incorrect because: A: Prodromal is the initial stage with vague, non-specific symptoms. B: Incubation is the period between exposure to the pathogen and the onset of symptoms. C: Convalescence is the recovery stage after the illness.