Nokea
The nurse is caring for a 12-year-old child hospitalized for internal injuries following a motor vehicle accident. For which medical treatment would the nurse ensure that an informed consent is completed beyond the one signed at admission?
- A. Diagnostic imaging
- B. Cardiac monitoring
- C. Blood testing
- D. Spinal tap
Correct Answer: D
Rationale: Certain procedures, however, require a specific process of informed consent, including major and minor surgery; invasive procedures such as lumbar puncture or bone marrow aspiration; treatments placing the child at higher risk, such as chemotherapy or radiation therapy; procedures or treatments involving research; photography involving children; and applying restraints to children.
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The nurse is monitoring a client with severe preeclampsia. What assessment finding requires immediate intervention?
- A. Blood pressure of 150/90 mmHg.
- B. Urine output of 25 mL/hr.
- C. Headache relieved by acetaminophen.
- D. Deep tendon reflexes +2.
Correct Answer: B
Rationale: Oliguria (urine output <30 mL/hr) may indicate worsening renal function or severe complications in preeclampsia.
A postpartum client calls the pediatric clinic to report that her 4-day old female newborn has a spot of blood on her diaper. Which of the following statements made by the nurse is most appropriate?
- A. Your newborn may have a urinary infection, continue to breastfeed frequently
- B. Your newborn has jaundice so it may need phototherapy
- C. This is a normal finding due to withdrawal of maternal hormones
- D. Your baby has an immature immune system, continue to breastfeed frequently
Correct Answer: C
Rationale: Pseudomenstruation is a normal finding due to hormonal withdrawal.
Which data must the nurse consider before administering Depo-Provera (medroxyprogesterone acetate) to a postpartum client?
- A. The capsule must be taken at the same time each day.
- B. The client must be taught to use sunscreen whenever in the sunlight.
- C. The medicine is contraindicated if the woman has lung or esophageal cancer.
- D. The client must use an alternate form of birth control for the first two months.
Correct Answer: C
Rationale: Medroxyprogesterone acetate is contraindicated in women with certain cancers.
The nurse notes that an older adult client receives only one visitor and asks the client if family members could be called. The client states, 'I consider her to be all of my family.' What would the nurse consider in responding to the client?
- A. The nurse could encourage the client to reconnect with other family members.
- B. The client defines who is and who is not part of the family without undue influence.
- C. The nurse realizes individuals exist without a family and do not often adopt substitutes.
- D. Family is more important to those individuals with a large number of family members.
Correct Answer: B
Rationale: It is important for nurses to remain neutral to all they hear and see in order to enhance trust and maintain open communication lines with all family members. Nurses need to remember that clients are experts of their own health and can define their own family.
What response by a client indicates effective postvasectomy teaching?
- A. I will measure my urinary output for two days.
- B. I will ejaculate the same amount of semen as I did before the surgery.
- C. I will refrain from having an erection until next week.
- D. I will irrigate the wound twice today and once more tomorrow.
Correct Answer: B
Rationale: Semen volume remains unchanged after vasectomy.