Nokea
The client is at greatest risk for developing -----and-------
- A. Placental abruption
- B. Hypoglycemia
- C. Heart failure
- D. Cervical Insufficiency
- E. Seizures
Correct Answer: A,E
Rationale: The correct answer is A (Placental abruption) and E (Seizures) because they are common complications during pregnancy. Placental abruption poses a risk of severe bleeding and fetal distress, leading to adverse outcomes. Seizures, specifically eclampsia, can occur due to uncontrolled hypertension in pregnancy, putting both the mother and baby at risk. Hypoglycemia (B), heart failure (C), and cervical insufficiency (D) are potential complications but are not the greatest risks compared to placental abruption and seizures in this context.
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Which of the following action should the nurse take?
- A. Determine if the AP has the skills to perform the test.
- B. Help the AP performed the blood glucose test
- C. Assign the AP to ask the client is taking his diabetic medication today
- D. Have AP check the medical record for prior blood glucose test results
Correct Answer: A
Rationale: The correct answer is A because the nurse should first assess if the AP has the necessary skills to perform the blood glucose test. This step is crucial to ensure patient safety and accurate test results. Helping the AP perform the test (B) without assessing their skills can lead to errors. Assigning the AP to ask about medication (C) is not directly related to the task at hand. Having the AP check records (D) is important but should come after confirming their skills. The other choices are not relevant to the immediate situation.
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.
A nurse is Inserting an indwelling urinary catheter to a male client. Which of the following actions should the nurse take?
- A. Cleanse the tip of the penis in a side to side motion
- B. Pick up the catheter 13 cm (5 in) from its tip
- C. Perform the cleansing procedure with a fresh swab two times
- D. Lift the penis so that it is perpendicular to the client's body
Correct Answer: D
Rationale: The correct answer is D: Lift the penis so that it is perpendicular to the client's body. This action helps straighten the urethra, allowing for easier insertion of the catheter. Lifting the penis also reduces the risk of trauma or injury during the procedure. Cleaning the tip of the penis in a side-to-side motion (choice A) can introduce bacteria into the urethra. Picking up the catheter 13 cm (5 in) from its tip (choice B) may contaminate the sterile end. Performing the cleansing procedure with a fresh swab two times (choice C) is not necessary and may increase the risk of irritation to the client's skin.
A nurse is assessing a client who has historic personality disorder. Which of the following manifestations should the nurse expect?
- A. Suspicious of others
- B. Callousness
- C. self-centered behavior
- D. violates others rights
Correct Answer: C
Rationale: The correct answer is C: self-centered behavior. Individuals with historic personality disorder often display self-centered behavior as they prioritize their own needs and desires above others. This is due to their excessive need for admiration and attention. The other options are incorrect because: A: Suspicious of others is more characteristic of paranoid personality disorder. B: Callousness is more indicative of antisocial personality disorder. D: Violates others' rights is a feature of antisocial personality disorder as well.
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.