Nokea
The nurse provides care to a school-age client who is prescribed amoxicillin suspension 250 mg PO for treatment of an upper respiratory infection (URI). Prior to administering the medication, the nurse provides which information to the client?
- A. Amoxicillin is an antibiotic that will help you get well.
- B. This medicine tastes just like fresh strawberries.
- C. You can't drink anything for an hour after taking this medicine.
- D. If you don't want to drink this medicine, I can give you a shot instead.
Correct Answer: A
Rationale: Informing the client that amoxicillin is an antibiotic that will help them recover provides age-appropriate education about the medication’s purpose, promoting understanding and adherence. Other options may mislead or unnecessarily alarm the child.
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A client who has undergone successful femoral-popliteal bypass grafting of the leg states to the nurse, 'I hope everything goes well after this and that I don't lose my leg. I'm so afraid that I'll have gone through this for nothing.' Which most therapeutic response should the nurse make to the client?
- A. I can understand what you mean. I'd be nervous too if I were in your shoes.
- B. This surgery is so successful that I wouldn't be concerned at all if I were you.
- C. Complications are possible, but you have a good deal of control if you make the lifestyle adjustments we talked about.
- D. Stress isn't helpful for you. You should probably just try to relax. You shouldn't worry unless something actually happens.
Correct Answer: C
Rationale: Clients frequently fear that they will ultimately lose a limb or become debilitated in some other way. Option 3 acknowledges the client's concerns and empowers the client to improve his or her health, which will ultimately reduce concern about the risk of complications. Option 1 feeds into the client's anxiety and is not therapeutic. Option 2 gives false reassurance. Option 4 is meant to be reassuring, but it offers no suggestions to empower the client.
The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team?
- A. Use Liquid PaperTM to 'white out' the resolved diagnosis on the care plan
- B. Recopy the care plan without the resolved diagnosis
- C. Write a nursing progress note indicating that the outcome goals have been achieved
- D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date
Correct Answer: D
Rationale: To discontinue a diagnosis once it has been resolved, cross it off with a single line or highlight it, then write initials and date. Some agency forms may require the nurse to put date and initials in a 'Date Resolved' column. Using Liquid PaperTM is not a legal way to amend client records as it can obscure the original documentation. Recopying the care plan without the resolved diagnosis can lead to confusion and inaccuracies in the client's record. Writing a nursing progress note indicating that the outcome goals have been achieved is important but should not be the sole method used to communicate the resolution of a nursing diagnosis. Drawing a single line through the resolved diagnosis on the care plan and documenting the nurse's initials and date is the most effective way to communicate the resolution of a nursing diagnosis to the healthcare team.
The nurse is observing the parents at the bedside of their small-for-gestational-age (SGA) infant, who was born at 27 weeks' gestation. The infant's mother states, 'She is so tiny and fragile. I'll never be able to hold her with all those tubes.' Considering this statement, which concern should the nurse identify for the mother?
- A. Impaired adjustment
- B. Trouble with family coping
- C. Potential for compromised parenting
- D. Difficulty understanding health concerns
Correct Answer: C
Rationale: Parents of a high-risk neonate, such as a preterm SGA infant, are at risk for compromised parenting. Parent-infant bonding is affected if the infant does not exhibit normal newborn characteristics. Option 1 involves the nonacceptance of a health status change or an inability to solve a problem or set a goal. Option 2 involves the identification of trouble with family coping. Option 4 addresses the condition's characteristics.
The client states to the nurse, 'I'm scheduled for outpatient surgery, but I live alone and my only child lives 300 miles away. I'm afraid. What happens if something goes wrong after I go home?' Which statement by the nurse is the most therapeutic?
- A. Don't worry about the details. This procedure is done all the time and generally without any problems. You'll be fine!'
- B. They say managed care is no care! Get an alarm system so that, if you fall, it will alert someone. If necessary, I'll come.'
- C. Your concern is well voiced. I advise you to call your son and insist that he come home immediately! You can't be too careful.'
- D. You seem very concerned about going home without help. Have you discussed your concerns with both your surgeon and your family?'
Correct Answer: D
Rationale: The client has verbalized concerns. In option 4, the nurse uses reflection to direct the client's feelings and concerns. In option 1 the nurse provides false reassurance and then minimizes the client's concerns. In option 2 the nurse is ventilating the nurse's own anger, frustration, and powerlessness. In addition, the nurse is trying to problem-solve for the client but is overly controlling and takes the decision making out of the client's hands. In option 3, the nurse is projecting the client's own fears, and the problem-solving suggested by the nurse will increase fear and anxiety in the client.
A client recovering from an acute myocardial infarction will be discharged in 1 day. Which client action on the evening before discharge suggests that the client is in the denial about his medical condition?
- A. Requests a sedative for sleep at 10:00 pm
- B. Expresses a hesitancy to leave the hospital
- C. Consumes 25% of foods and fluids given for supper
- D. Walks up and down three flights of stairs unsupervised
Correct Answer: D
Rationale: Ignoring activity limitations and avoiding lifestyle changes are signs of the denial stage. Walking three flights of stairs should be a supervised activity during this phase of the recovery process. Option 1 is an appropriate client action on the evening before discharge. Option 2 may be a manifestation of anxiety or fear rather than denial. Option 3 is a manifestation of depression rather than denial.