Nokea
The LPN on shift notices a client coming into the clinic with bruises on his arm. The client seems very afraid and doesn't speak much, which concerns the nurse because these are signs of physical abuse. The nurse should ____.
- A. use therapeutic communication to talk to the client and offer support while reporting the findings to the appropriate authorities based on the state requirements and protocols
- B. report the findings to the appropriate authorities based on the state requirements and protocols
- C. ignore the bruises, as this is not why the client is being treated and is not appropriate for the nurse to address
- D. report the suspected abuse to another nurse and collaborate on how to handle it
Correct Answer: B
Rationale: In cases of suspected abuse, healthcare providers have a legal and ethical obligation to report such incidents to the relevant authorities. This not only ensures the safety and well-being of the client but also helps in preventing further harm. Option A is incorrect as attempting to gather evidence of abuse may interfere with the official investigation and is not the nurse's role. Offering support is crucial, but the priority is to report the findings to the appropriate authorities. Option C is incorrect as ignoring signs of abuse goes against the duty of a healthcare provider to protect their clients. Option D is incorrect as reporting suspected abuse to other nurses without involving the appropriate authorities may delay necessary actions and intervention.
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Which of the following substances need to be assessed when completing a family health assessment?
- A. coffee, tea, cola, cocoa, and other substances
- B. alcohol, tobacco, and illegal substances
- C. medicines prescribed by a physician
- D. all of the above
Correct Answer: D
Rationale: When completing a family health assessment, it is essential to assess all substances consumed by family members, including coffee, tea, cola, cocoa, alcohol, tobacco, illegal substances, and medicines prescribed by a physician. Understanding the complete picture of substance use within the family is crucial for identifying potential health risks and providing appropriate care. Choice D, 'all of the above,' is the correct answer as it encompasses the comprehensive assessment of all substances. Choices A, B, and C are incorrect as they only present partial aspects of substance assessment and do not cover the full range of substances that should be evaluated in a family health assessment.
When inspecting the client's eyelids for ptosis, the nurse is checking for which abnormality?
- A. Drooping
- B. Pupil dilation
- C. Pupil constriction
- D. Deviation of ocular movements
Correct Answer: A
Rationale: When a nurse inspects a client's eyelids for ptosis, they are checking for drooping. Ptosis is a condition characterized by the drooping of the eyelids and can be associated with various disorders such as myasthenia gravis, dysfunction of cranial nerve III, and Bell's palsy. Pupil dilation and constriction are assessed using a flashlight to check pupillary response. Deviation of ocular movements is evaluated by leading the client's eyes through the six cardinal positions of gaze. Therefore, in this scenario, the correct answer is 'Drooping' as it specifically relates to the abnormality associated with ptosis.
While a client is on total parenteral nutrition, which of the following values should the nurse monitor closely?
- A. calcium
- B. magnesium
- C. glucose
- D. cholesterol
Correct Answer: C
Rationale: Glucose should be monitored closely when a client is on total parenteral nutrition due to the high glucose concentration in the solutions. Monitoring glucose levels is crucial to prevent complications such as hyperglycemia or hypoglycemia. Calcium and magnesium are usually monitored to assess electrolyte imbalances, while cholesterol levels are not directly impacted by total parenteral nutrition. Therefore, choices A, B, and D are not the primary values that need close monitoring during total parenteral nutrition.
A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?
- A. Risk for Self-Harm
- B. Body Image Disturbance
- C. Ineffective Role Performance
- D. Powerlessness
Correct Answer: B
Rationale: The correct nursing diagnosis for this client is 'Body Image Disturbance.' The client's statement reflects concerns about self-identity and feeling incomplete due to infertility, which aligns with Body Image Disturbance. The statement does not directly indicate a risk for self-harm, so 'Risk for Self-Harm' is not the correct choice. 'Ineffective Role Performance' is not the best option as it does not address the client's primary concern regarding self-image. While 'Powerlessness' could be appropriate if the client expressed feelings of powerlessness related to infertility, it is not the most suitable diagnosis based on the given statement.
A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:
- A. The physician in charge of the case is the sole person allowed to decide whether organ donation can occur.
- B. The client's legally responsible party may make the decision for organ donation for the donor if the client is unable to do so.
- C. The organ procurement organization makes the decision regarding which organs to harvest.
- D. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process.
Correct Answer: A
Rationale: While the physician plays a crucial role in the process of organ donation, they are not the sole decision-maker. The client's legally responsible party may make the decision for organ donation if the client is unable to do so. Additionally, the organ procurement organization is responsible for determining which organs are suitable for donation. Therefore, the statement that the physician in charge is the sole person allowed to decide whether organ donation can occur is incorrect. The correct answer is A. Choices B, C, and D are true statements as they highlight the involvement of the legally responsible party, the organ procurement organization, and the donor/legally responsible party, physician, and organ-procurement organization in the organ donation process respectively.