Nokea
The nurse is caring for a client with a tracheostomy. Which of the following interventions should be included in the plan of care? Select all that apply.
- A. Suction the tracheostomy as needed.
- B. Clean the inner cannula daily.
- C. Change the tracheostomy ties weekly.
- D. Monitor for signs of skin breakdown.
- E. Keep the tracheostomy tube uncuffed.
Correct Answer: A, B, C, D
Rationale: Suctioning, cleaning the cannula, changing ties, and monitoring for skin breakdown are essential for tracheostomy care. Cuffed tubes are used in specific cases.
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A client with acute stress disorder is telling the nurse about the tornado that leveled his house and killed his wife and baby while he was out of town on business. He states, 'If only I'd been at home, I could have saved them.' Which of the following responses would be most appropriate?
- A. Don't blame yourself; you'll only feel worse.'
- B. It's not your fault; so stop feeling so guilty.'
- C. You might not have been at home.'
- D. You couldn't have prevented the tornado; it just happened.'
Correct Answer: D
Rationale: Acknowledging the uncontrollable nature of the tornado helps the client process guilt rationally, supporting coping with acute stress disorder.
You are providing care to a permanently disabled Iraqi war veteran who is 28 years of age. When he returned home from the war at the age of years of age 2 years ago he was deemed permanently disabled by both the Veterans Administration (VA) and the Social Security Administration. He receives a substantial monthly service connected disability check from the Veterans Administration and he has no spouse or legal dependents. Which type of governmental health insurance is he now entitled to?
- A. Only the VA health care services because he is not 65 years of age
- B. Medicare because he has been deemed permanently disabled for 2 years
- C. Medicaid because he is permanently disabled and not able to work
- D. Choices B and C
Correct Answer: B
Rationale: Individuals deemed permanently disabled by the Social Security Administration for at least 24 months are eligible for Medicare, regardless of age . The veteran is also eligible for VA healthcare, but option A incorrectly states 'only' VA services. Medicaid eligibility depends on income and state criteria, which are not confirmed here.
You are working in a community pediatric health clinic. Which developmental task should you apply into your practice?
- A. You should apply the principles of initiative when caring for preschool children.
- B. You should apply the principles of sensorimotor thought when caring for preschool children.
- C. You should apply the principles of intimacy when caring for the adolescent.
- D. You should apply the principles of concrete operations when caring for the adolescent.
Correct Answer: A
Rationale: According to Erikson's developmental stages, preschool children (ages 3-5) are in the stage of Initiative vs. Guilt, where they develop a sense of purpose through exploration and play. This is the appropriate developmental task to apply in a pediatric clinic for this age group.
During the admission interview, an adult client reveals that, as a child, she was sexually abused by her uncle and a male cousin. She reports that she cuts the skin of her arms, legs, and abdomen. In addition to having the client sign a no-harm contract, which nursing intervention is most important?
- A. Assist the client with finding safe ways to express her anger.
- B. Talk with the client about confronting her uncle and cousin directly.
- C. Defer talking about the abuse to prevent further self-mutilation.
- D. Discuss the possibility of the client suing her relatives for their abuse.
Correct Answer: A
Rationale: Helping the client find safe ways to express anger addresses the self-harm behavior therapeutically, promoting coping skills and safety.
You are caring for a postoperative client who is complaining of abdominal distention and flatus. Which intervention would you most likely do for this client?
- A. A cleansing enema
- B. A retention enema
- C. A return-flow enema
- D. A laxative
Correct Answer: C
Rationale: A return-flow enema is used to relieve gas and distention by introducing and withdrawing fluid to stimulate gas expulsion.