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The nurse is performing an assessment on a primigravida client who has been a marathon runner for several years. The client verbalizes concern because she is no longer able to run in marathons and is concerned about the brown discoloration on her face and her increasing size. Which statements by the nurse are therapeutic?
- A. I can see you're disappointed at not being able to run.
- B. Tell me how you are feeling about the changes in your body.
- C. Don't worry. Your body will go back to normal after delivery.
- D. You need to ask your obstetrician about whether or not you can run.
- E. Wait and see. You will be back to marathon running after delivery before you know it.
- F. Some of the changes in pregnancy are permanent and that is the price that you have to pay for that bundle of joy.
Correct Answer: A,B
Rationale: The client is concerned about the body changes and life changes being experienced as a result of pregnancy. Therapeutic communication techniques include focusing on the client's feelings and concerns and acknowledging these concerns by the techniques of clarifying and encouraging discussion of feelings. Telling a client 'not to worry,' placing the client's feelings on hold, and avoiding discussion of the client's feelings are nontherapeutic communication techniques.
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The nurse provides information to a client who is scheduled for the implantation of an implantable cardioverter defibrillator (ICD) regarding care after implantation. The nurse tells the client that there is a need to keep a diary. What information should the nurse provide concerning the primary purpose of the diary?
- A. Analyze which activities to avoid.
- B. Document events that precipitate a countershock.
- C. Provide a count of the number of shocks delivered.
- D. Record a variety of data that are useful for the primary health care provider during medical management.
Correct Answer: D
Rationale: The primary purpose of the ICD diary is to record comprehensive data (date, time, activity, symptoms, number of shocks, and post-shock feelings) for the provider to adjust medical management, particularly medication therapy. Other options are specific aspects of this broader purpose.
The nurse provides discharge instructions to the mother of a child who was hospitalized for heart surgery. Which instruction should the nurse provide to the mother?
- A. The child can play outside for short periods of time.
- B. After bathing, rub lotion and sprinkle powder on the incision.
- C. The child may return to school 1 week after hospital discharge.
- D. Notify the primary health care provider if the child develops a fever greater than 100.5°F (38°C).
Correct Answer: D
Rationale: Notifying the primary health care provider if the child develops a fever greater than 100.5°F (38°C) is critical to detect potential infections post-heart surgery. The child should not play outside for several weeks to avoid infection or injury. No creams, lotions, or powders should be applied to the incision until fully healed. The child should not return to school until 3 weeks after discharge, starting with half days.
The nurse is monitoring a client diagnosed with type 1 diabetes mellitus. Today's blood work reveals a glycosylated hemoglobin level of 10%. The nurse creates a teaching plan based on the understanding that this result indicates which finding?
- A. A normal value that indicates that the client is managing blood glucose control well
- B. A value that does not offer information regarding the client's management of the disease
- C. A low value that indicates that the client is not managing blood glucose control very well
- D. A high value that indicates that the client is not managing blood glucose control very well
Correct Answer: D
Rationale: Glycosylated hemoglobin is a measure of glucose control during the 6 to 8 weeks before the test. It is a reliable measure for determining the degree of glucose control in diabetic clients over a period of time, and it is not influenced by dietary management 1 to 2 days before the test is done. The glycosylated hemoglobin level should be 6.0% or less for a client diagnosed with diabetes mellitus, with elevated levels indicating poor glucose control.
Which should the nurse identify as a situational crisis?
- A. Divorce
- B. Retirement
- C. Loss of a job
- D. An earthquake
- E. The birth of a child
- F. Death of a loved one
Correct Answer: A,C,F
Rationale: A situational crisis arises from an external rather than an internal source and often is unanticipated. Examples of external situations that can precipitate a situational crisis include divorce, the loss of a job, the death of a loved one, an abortion, a change in job, a change in financial status, and severe physical or mental illness. A maturational crisis occurs at a developmental stage; examples include marriage, the birth of a child, and retirement. An adventitious crisis, or crisis of disaster, is not a part of everyday life and is unplanned or accidental. This type of crisis can result from a natural disaster (flood, fire, earthquake), a national disaster (acts of terrorism, war, riots, airplane crashes), or a crime of violence (rape, assault, murder, bombing, spousal or child abuse).
A community health nurse is lecturing students at a nearby community college about high-risk behavior. Which of the following should the nurse include in the lecture?
- A. Suicide is the most common cause of death in this age group.
- B. Cancer is the third most common cause of death in this age group.
- C. Homicide is the second most common cause of death in this age group.
- D. College-age students are more likely to die from unintentional injuries.
Correct Answer: D
Rationale: Unintentional injuries (e.g., car accidents) are the leading cause of death in college-age students. Suicide and homicide rank lower, and cancer is not third.