Nokea
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.
You may also like to solve these questions
The nurse is working with a group of community health members to develop a plan to address the special health needs of women. Which educational program would the group most likely identify as the priority?
- A. risk reduction strategies for diabetes
- B. methods for smoking cessation
- C. ways to adopt a heart-healthy lifestyle
- D. importance of cancer screening and early detection
Correct Answer: C
Rationale: The group needs to address cardiovascular disease, the number one cause of death in women regardless of racial or ethnic group. Thus, education for adopting a heart-healthy lifestyle would be the priority.
As a nurse providing anticipatory guidance to parents of newborns, for which reason would you advise against allowing young siblings to feed an infant?
- A. Increased risk of aspiration
- B. Increased risk of mouth injury
- C. increased risk of bowel obstruction
- D. Increased risk of vomiting
Correct Answer: A
Rationale: Young children may not properly handle the infant, increasing the risk of aspiration.
A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate?
- A. Moderate lochia rubra
- B. Fundus three fingerbreadths above the umbilicus
- C. Moderate swelling of the labia
- D. Blood pressure 130/84 mm Hg
Correct Answer: B
Rationale: A fundus three fingerbreadths above the umbilicus indicates that the uterus is not adequately contracting, which can obstruct the flow of urine from the bladder. Postpartum clients often experience urinary retention due to decreased sensation in the bladder, trauma from delivery, and decreased bladder tone. Failure to empty the bladder promptly can lead to urinary retention and potential complications such as urinary tract infections or bladder distention. Therefore, the nurse should be alert to the client's need to urinate when assessing the fundal height.
A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Urine protein concentration 200 mg/ 24 hr.
- B. Creatinine 0.8 mg/ Dl
- C. Hemoglobin 14.8 g/ dL
- D. Platelet Count 60.000/ mm3
Correct Answer: D
Rationale: A platelet count of 60,000/mm3 is significantly low and can be indicative of thrombocytopenia, a potential complication of preeclampsia known as HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count). Thrombocytopenia increases the risk of bleeding complications during pregnancy and delivery, requiring prompt evaluation and management by the healthcare provider. The nurse should report this finding immediately to prevent any adverse outcomes for the client and baby.
The nurse is reviewing a copy of the U.S. Surgeon General's Report, Healthy People 2020. Which nursing action best reflects the nurse fostering this health care agenda?
- A. The nurse signs up for classes to obtain an advanced degree in nursing.
- B. The nurse volunteers at a local health care clinic providing free vaccinations for low-income populations.
- C. The nurse performs an in-service on basic hospital equipment for student nurses.
- D. The nurse compiles nursing articles on evidence-based practices in nursing to present at a hospital training seminar.
Correct Answer: B
Rationale: Healthy People 2020 is a comprehensive health promotion and disease prevention agenda that is working toward improving the quantity and quality of life for all Americans.