Nokea
The community health nurse is working in a multi-ethnic health center. In what situation should the nurse intervene?
- A. An Asian-American mother reports using cupping to treat infection, resulting in a pattern of red round marks on her toddler's back.
- B. A Hispanic pregnant client who is often late for appointments, arrives late for today's appointment.
- C. A Native-American who is being interviewed will not make direct eye contact when asked about violence in the home.
- D. An African-American infant who is spitting up milk has lost 6 ounces since last week's clinic visit.
Correct Answer: D
Rationale: The correct answer is D because an African-American infant losing weight rapidly is a sign of potential malnutrition or health issue that requires immediate intervention. The nurse should assess the infant's feeding, growth, and health status to address the problem promptly.
Choice A is incorrect as cupping is a cultural practice that may not necessarily harm the child and should be respected. Choice B is incorrect as being late for appointments is not a direct health risk that requires immediate intervention. Choice C is incorrect as avoiding direct eye contact is a cultural norm for some Native-American individuals and does not indicate a health emergency.
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A client with liver cirrhosis is being educated about managing their condition. Which statement by the client indicates a need for further teaching?
- A. I will avoid drinking alcohol
- B. I need to limit my salt intake
- C. I can take acetaminophen for pain
- D. I should eat a balanced diet
Correct Answer: C
Rationale: The correct answer is C: "I can take acetaminophen for pain." Acetaminophen can be harmful to the liver, especially in individuals with liver cirrhosis. The liver is responsible for metabolizing acetaminophen, and in cirrhosis, its function is impaired, leading to potential toxicity. Choice A is correct as alcohol can worsen liver damage. Choice B is correct as excess salt can lead to fluid retention and complications. Choice D is correct as a balanced diet is important for overall health. Therefore, the statement about taking acetaminophen indicates a need for further teaching.
The sister of a patient diagnosed with BRCA gene¢â‚¬"related breast cancer asks the nurse, 'Do you think I should be tested for the gene?' Which response by the nurse is most appropriate?
- A. In most cases, breast cancer is not caused by the BRCA gene.
- B. It depends on how you will feel if the test is positive for the BRCA gene.
- C. There are many things to consider before deciding to have genetic testing.
- D. You should decide first whether you are willing to have a bilateral mastectomy.
Correct Answer: C
Rationale: The correct answer is C because genetic testing for the BRCA gene involves complex considerations beyond just the test results. By stating that there are many things to consider before deciding to have genetic testing, the nurse acknowledges the importance of discussing the potential implications of the test result, such as emotional, social, and medical factors. This response promotes informed decision-making and empowers the patient to make a well-considered choice.
Choices A, B, and D are incorrect:
A: This statement is inaccurate as a significant proportion of breast cancers are indeed linked to the BRCA gene mutations.
B: This response oversimplifies the decision-making process by focusing solely on emotional aspects, neglecting other critical factors that should be considered before genetic testing.
D: This option is not appropriate as it suggests a specific treatment option (bilateral mastectomy) without addressing the broader aspects of genetic testing and decision-making.
What side effect should be monitored for in a patient with chronic heart failure taking spironolactone?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypernatremia
Correct Answer: B
Rationale: The correct answer is B: Hyperkalemia. Spironolactone is a potassium-sparing diuretic commonly used in patients with heart failure. It works by blocking the aldosterone receptor, leading to potassium retention and potential hyperkalemia. Monitoring potassium levels is crucial as hyperkalemia can increase the risk of arrhythmias and other cardiac complications in heart failure patients.
A: Hypokalemia is incorrect because spironolactone typically causes potassium retention.
C: Hyponatremia and D: Hypernatremia are incorrect as spironolactone does not directly affect sodium levels.
In summary, monitoring for hyperkalemia is essential in patients with heart failure taking spironolactone to prevent adverse cardiac events.
A client who is 2 days postoperative reports severe pain and swelling in the right leg. The nurse notes that the leg is warm and red. What is the nurse's priority action?
- A. Apply a warm compress to the affected leg.
- B. Elevate the leg on pillows.
- C. Measure the circumference of the leg.
- D. Notify the healthcare provider immediately.
Correct Answer: D
Rationale: The correct answer is D: Notify the healthcare provider immediately. This is the priority action because the client is experiencing severe pain, swelling, warmth, and redness in the leg, which are signs of potential deep vein thrombosis (DVT) or other serious complications postoperatively. The healthcare provider needs to be informed promptly to assess and initiate appropriate treatment to prevent further complications.
A: Applying a warm compress may worsen the condition if it is DVT, as heat can promote clot formation.
B: Elevating the leg on pillows may not address the underlying cause of the symptoms and delay necessary intervention.
C: Measuring the circumference of the leg may provide some information, but it is not as urgent as notifying the healthcare provider for immediate assessment and intervention.
The patient admitted with diabetic ketoacidosis has rapid, deep respirations. What action should the nurse take?
- A. Administer the prescribed PRN lorazepam (Ativan).
- B. Start the prescribed PRN oxygen at 2 to 4 L/min.
- C. Administer the prescribed normal saline bolus and insulin.
- D. Encourage the patient to practice guided imagery for relaxation.
Correct Answer: C
Rationale: The correct answer is C, administer the prescribed normal saline bolus and insulin. In diabetic ketoacidosis, rapid, deep respirations, known as Kussmaul breathing, occur due to compensatory mechanisms to lower blood pH. Normal saline bolus helps correct dehydration and insulin therapy helps lower blood sugar levels, leading to improved acidosis. Option A is incorrect as lorazepam does not address the underlying cause of the rapid respirations. Option B is incorrect as oxygen is not the priority in this situation. Option D is incorrect as guided imagery does not address the physiological needs of the patient in this critical condition.