Nokea
The nurse is planning discharge care with the parents of a 16-year-old boy who recently attempted suicide. The nurse should advise the parents to tell the nurse if their son:
- A. Expresses a desire to date.
- B. Decides to try out for an extracurricular activity.
- C. Gives away valued personal items.
- D. Desires to spend more time with his friends.
Correct Answer: C
Rationale: Giving away valued items is a warning sign of suicidal intent, requiring immediate reporting. The other behaviors are normal adolescent activities.
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A client being discharged from the hospital with a diagnosis of gastric ulcer has a prescription for sucralfate 1 gram by mouth 4 times daily. The nurse determines that the client understands proper use of the medication when the client states the intention to take the medication at which time?
- A. With meals and at bedtime
- B. Every 6 hours around the clock
- C. One hour after meals and at bedtime
- D. One hour before meals and at bedtime
Correct Answer: D
Rationale: Sucralfate is an antiulcer medication. The medication should be scheduled for administration 1 hour before meals and at bedtime. This timing will allow the medication to form a protective coating over the ulcer before it becomes irritated by food intake, gastric acid production, and mechanical movement. The other options are incorrect.
An infant with increased intracranial pressure (ICP) on a regular diet vomits while eating dinner. Which of the following should the nurse do next?
- A. Put the child on nothing-by-mouth (NPO) status.
- B. Call to report this event to the physician.
- C. Wait a few minutes, then refeed the child.
- D. Administer the prescribed antiemetic.
Correct Answer: B
Rationale: Vomiting in an infant with increased ICP may indicate worsening pressure, requiring immediate physician notification.
A client is experiencing symptoms of early alcohol withdrawal. The client's blood pressure is 150/85 mm Hg and the pulse is 98 bpm. The nurse should:
- A. Administer lorazepam (Ativan).
- B. Apply arm and leg restraints.
- C. Assign an unlicensed assistive personnel to sit with the client.
- D. Notify the physician.
Correct Answer: D
Rationale: Notifying the physician is the priority to obtain orders for managing alcohol withdrawal symptoms, which may require medications like lorazepam.
Which federal law is most closely associated with the highly restrictive 'need to know'?
- A. The Patient Self Determination Act
- B. The Mental Health Parity Act
- C. The Health Insurance Portability and Accountability Act
- D. The Americans with Disabilities Act of 1990
Correct Answer: C
Rationale: The Health Insurance Portability and Accountability Act (HIPAA) enforces the 'need to know' principle, restricting access to protected health information to only those who require it for their job functions.
A new breast-feeding mother experiencing breast engorgement is provided with instructions regarding care for the condition. Which statement by the mother indicates to the nurse that she possesses an understanding of the measures that will provide comfort for the engorgement?
- A. I will breast-feed using only one breast.
- B. I will apply cold compresses to my breasts.
- C. I will avoid the use of a bra while my breasts are engorged.
- D. I will massage my breasts before feeding to stimulate letdown.
Correct Answer: D
Rationale: Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate letdown, alternating the breasts during feeding, taking a warm shower or applying warm compresses just before feeding, and wearing a supportive well-fitting bra at all times. None of the other options suggest correct measures.