Nokea
A nurse is caring for a client whose child died from cancer. The client states 'it's hard to go on without him'. which of the following questions should the nurse ask the client first?
- A. What has helped you through difficult times in the past?
- B. Has anyone in your family committed suicide?
- C. Is there anyone you would like involved in your care?
- D. Are you thinking about ending your life?
Correct Answer: D
Rationale: The correct answer is D: Are you thinking about ending your life? This question is crucial as it directly addresses the client's statement about finding it hard to go on. It assesses the client's suicidal ideation and determines the level of risk for self-harm or suicide. It prioritizes the client's safety and well-being.
Choice A is incorrect because it does not directly address the immediate concern of potential suicide risk. Choice B is irrelevant and may lead to unnecessary distress for the client. Choice C is important but not as urgent as assessing for suicidal ideation.
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For each potential action, click to specify if the action is indicated or contraindicated for the client.
- A. Allow the client to watch TV at high volume
- B. Ask the client about the content of their hallucinations
- C. Instruct the client on expected hygiene practices
- D. Assess the client for suicidal ideation
- E. Place the client in a room near the activity room
Correct Answer: B,D
Rationale: [
B: Asking the client about the content of their hallucinations is indicated to gather important information for assessment and treatment planning.
D: Assessing the client for suicidal ideation is crucial to ensure their safety and provide appropriate interventions.
A: Allowing the client to watch TV at high volume is contraindicated as it may exacerbate symptoms or disturb others.
C: Instructing the client on expected hygiene practices may not be a priority compared to assessing hallucinations and suicidal ideation.
E: Placing the client in a room near the activity room is not mentioned in the question and does not address the client's immediate needs.]
For each potential assessment finding, click to specify if the finding is consistent with chorioamnionitis or preeclampsia. Each finding may support more than one disease process.
Note: Each column must have at least 1 response option selected.
- A. Elevated uric acid level
- B. Blurred vision
- C. Decreased platelet count
- D. Purulent amniotic fluid
- E. Fever
Correct Answer: B,C,D,E
Rationale: Findings like fever, purulent amniotic fluid, decreased platelets, and elevated uric acid support chorioamnionitis. Blurred vision is more indicative of preeclampsia.
Select the 2 findings that require immediate follow-up.
- A. Blood pressure
- B. Duration of contraction
- C. Fetal heart rate
- D. Fetal station
- E. Characteristics of amniotic fluid
Correct Answer: C,E
Rationale: An elevated fetal heart rate and meconium-stained amniotic fluid indicate potential distress, necessitating urgent intervention.
The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?
- A. Assault
- B. Battery
- C. False imprisonment
- D. Negligence
Correct Answer: A
Rationale: The correct answer is A: Assault. Assault is the intentional act causing the apprehension of harmful or offensive contact. In this scenario, the statement made by the AP creates fear or apprehension of harm, even though no physical contact has occurred yet.
Choice B (Battery) involves actual physical contact, which is not present here. Choice C (False imprisonment) involves restricting someone's movement, not applicable in this situation. Choice D (Negligence) is the failure to exercise reasonable care, which is not the case here. The correct answer, assault, best fits the scenario described.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Instruct the client to avoid five vaccines
- B. Instruct the client to avoid foods high in purines
- C. Instruct the client to use mild soaps for cleansing skin.
- D. Gout
- E. Rheumatoid arthritis (RA)
- F. Systemic lupus erythematosus (SLE)
- G. ANA
Correct Answer: B
Rationale: Gout is characterized by elevated uric acid levels and responds to dietary modifications. Monitoring uric acid ensures treatment effectiveness.