Nokea
Nurse reviewing CDC's immunization recommendations with parents of adolescent. Which should nurse include in this discussion?
- A. "rotavirus"
- B. varicella
- C. herpes zoster
- D. HPV
- E. seasonal influenza
Correct Answer: B, D, E
Rationale: The correct answers are B (varicella), D (HPV), and E (seasonal influenza) because these are recommended immunizations for adolescents by the CDC. Varicella vaccine protects against chickenpox, HPV vaccine prevents certain types of cancers, and seasonal influenza vaccine helps prevent the flu. Rotavirus (A) is typically given to infants, not adolescents. Herpes zoster (C) is recommended for older adults, not adolescents.
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Nurse talking to parents of school-age child who describe many issues that concern them. Which problem should nurse identify as priority for more assessment & intervention?
- A. He doesn't keep up with other kids in activities like running & jumping
- B. He keeps trying to find ways around household rules; he always wants to make deals with us
- C. We think he is trying too hard to excel in math just to get top grades in his class
- D. He is always afraid the kids at school will laugh at him b/c he likes to sing & write poems
Correct Answer: A
Rationale: The correct answer is A because the child's inability to keep up with other kids in physical activities like running and jumping could indicate underlying physical or developmental issues that require further assessment and intervention. This could be a sign of motor skill delays, muscle weakness, or coordination problems that may impact the child's overall physical health and well-being. Options B, C, and D focus on behavioral, academic, and social issues which are important but not as urgent as addressing potential physical limitations that could affect the child's daily functioning and quality of life.
Nurse is counseling older adult who describes having difficulty with several issues. Which problem should nurse identify as priority for more assessment & intervention?
- A. "I spent my whole life dreaming about retirement
- B. & now I wish I had my job back"
- C. It's been so stressful for me to have to depend on my son to help around the house
- D. I just heard my friend Al died. That's the 3rd one in 3 months.
- E. I'm struggling with helping out in my community. I just don't know what I can do.
Correct Answer: D
Rationale: The correct answer is D. The nurse should prioritize assessing and intervening in the older adult's grief over losing friends. This is crucial as multiple recent losses can lead to increased risk of depression and isolation. It is essential to address feelings of loss and provide support. Choice A focuses on retirement dreams, which may not be as urgent. Choice B indicates job-related regret. Choice C mentions stress from dependence on son. These issues are important but do not pose immediate risks to mental health and well-being compared to dealing with multiple recent deaths. Choices E, F, and G do not provide relevant information to prioritize over grief from recent losses.
Nurse providing discharge instructions to client with prescription for oxygen use in home. Which should nurse teach about using oxygen safely in his home? (Select all that apply.)
- A. Family members who smoke must be at least 10 ft from client when his oxygen is on
- B. Nail polish shouldn't be used near client receiving oxygen
- C. A 'No Smoking' sign should be placed on front door
- D. Cotton bedding/clothing should be replaced with items made from wool
- E. Fire extinguisher should be readily available in home
Correct Answer: B,C,E
Rationale: Correct Answer: B, C, E
Rationale:
B: Nail polish contains flammable substances, which can pose a fire hazard near oxygen. Teaching the client to avoid using nail polish near oxygen is essential for safety.
C: Placing a 'No Smoking' sign on the front door serves as a clear reminder to visitors and family members about the importance of not smoking near the client using oxygen.
E: Having a fire extinguisher readily available in the home is crucial in case of a fire emergency, especially when oxygen is being used, as oxygen can accelerate combustion.
Incorrect Choices:
A: While it is important for family members who smoke to stay away from the client when oxygen is on, the 10 ft rule is arbitrary and not evidence-based.
D: There is no significant safety benefit in replacing cotton bedding/clothing with items made from wool regarding oxygen use in the home.
Summary: Teaching about avoiding flammable substances like nail polish, displaying a 'No Smoking' sign,
Nurse observes assistive personnel (AP) reprimanding a client for not using urinal properly. The AP tells him she will put a diaper on him if he doesn't use urinal more carefully next time. Which of the following torts is AP committing?
- A. Assault
- B. Battery
- C. False imprisonment
- D. Invasion of privacy
Correct Answer: A
Rationale: The correct answer is A: Assault. Assault is the intentional act that causes another person to fear that they will be touched in a harmful or offensive manner. In this scenario, the AP's threat to put a diaper on the client if he doesn't use the urinal properly next time is an intentional act that instills fear in the client. This threat constitutes assault because it creates a reasonable apprehension of harmful or offensive contact.
Choice B (Battery) involves actual physical contact without consent, which is not present in this scenario. Choice C (False imprisonment) involves restricting someone's freedom of movement, which is not evident here. Choice D (Invasion of privacy) pertains to disclosing private information, which is not the issue at hand. Therefore, the correct answer is A as it best aligns with the scenario presented.
Nurse observes smoke coming from under door of staff lounge. Which is priority action by the nurse?
- A. Extinguish fire
- B. Pull fire alarm
- C. Evacuate the clients
- D. Close all open doors on the unit
Correct Answer: C
Rationale: The priority action for the nurse in this scenario is to evacuate the clients (Choice C). This is because ensuring the safety of the clients is the most critical responsibility in a healthcare setting. Evacuating them immediately helps prevent harm and ensures their well-being. Pulling the fire alarm (Choice B) may be necessary but not the top priority as it does not directly ensure client safety. Extinguishing the fire (Choice A) may put the nurse at risk and delay client evacuation. Closing doors (Choice D) may contain the fire but does not address the immediate need of client safety.