Nokea
The nurse should notify the provider for which of the following findings?
- A. Baseline fetal heart rate 115/min
- B. Three uterine contractions within 10 minutes
- C. Prolonged decelerations
- D. Moderate variability in the fetal heart rate
Correct Answer: C
Rationale: The correct answer is C: Prolonged decelerations. This finding indicates potential fetal distress, requiring immediate provider notification to assess and intervene. Baseline fetal heart rate (A) within normal range is reassuring. Three uterine contractions (B) could be normal. Moderate variability (D) is a positive sign of fetal well-being. The focus should be on abnormal findings like prolonged decelerations (C) that may indicate compromised fetal oxygenation.
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Which risk factor should the nurse include as the best predictor of future violence?
- A. Previous violent behavior
- B. Low self-esteem
- C. Substance use disorder
- D. A history of depression
Correct Answer: A
Rationale: The correct answer is A: Previous violent behavior. This is the best predictor of future violence because past behavior is a strong indicator of future actions. Individuals who have a history of violent behavior are more likely to exhibit violent tendencies again. Low self-esteem (B), substance use disorder (C), and a history of depression (D) can contribute to increased risk of violence, but they are not as reliable predictors as previous violent behavior. A history of violence is a key factor in assessing the potential for future violent acts.
Which of the following guidelines should the nurse include?
- A. Document the client's condition every 15 minutes.
- B. Attach the restraint straps to the side rails of the bed.
- C. Use a square knot to secure the restraint.
- D. Ensure there is at least a 2-inch gap between the restraint and the client's body.
Correct Answer: A
Rationale: The correct answer is A: Document the client's condition every 15 minutes. This guideline is crucial for monitoring the client's status, detecting any changes promptly, and ensuring their safety. Documenting every 15 minutes allows for timely intervention and assessment.
Choice B is incorrect because attaching restraint straps to the side rails can lead to entrapment and harm.
Choice C is incorrect as a square knot is not recommended for securing restraints due to the risk of difficulty in quick release during emergencies.
Choice D is incorrect as a 2-inch gap between the restraint and the client's body can increase the risk of injury or self-removal.
A nurse is teaching a client about advanced directives. Which of the following statements by the client indicate an understanding of the teaching?
- A. A living will is a document that includes my wishes about health care decisions.
- B. My provider will make my health care decisions if I complete advanced directives.
- C. Advanced directives outline who inherits my material possessions in the event of my death.
- D. My partner needs to be present as a witness when I sign my living will
Correct Answer: A
Rationale: The correct answer is A: A living will is a document that includes my wishes about health care decisions. This statement demonstrates an understanding of advanced directives as a living will specifically pertains to healthcare decisions. It shows that the client comprehends that a living will outlines their preferences for medical treatment in case they are unable to communicate.
Choice B is incorrect because advanced directives are about the client's own wishes, not the provider making decisions. Choice C is incorrect as advanced directives do not pertain to material possessions but rather to healthcare decisions. Choice D is incorrect because a witness is typically required for legal purposes when signing a living will, but the presence of a partner is not mandatory.
Which of the following actions should the nurse take to reduce the risk for client injury?
- A. Keep the television on during the night
- B. Place the bedside table at the foot of the bed
- C. Raise the side rails up when the client is in bed
- D. Assist the client to the toilet frequently
Correct Answer: C
Rationale: The correct answer is C: Raise the side rails up when the client is in bed. This action helps prevent falls and injuries by providing a physical barrier to keep the client from rolling out of bed. Keeping the television on (choice A) does not directly address client safety. Placing the bedside table at the foot of the bed (choice B) may not prevent falls or injuries. Assisting the client to the toilet frequently (choice D) is important for personal care but does not directly reduce the risk for client injury.
Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
- A. Initiate seclusion protocol.
- B. Tell the client, 'You seem to be very upset.'
- C. Stand directly in front of the client and maintain eye contact.
- D. Speak in a firm and authoritative tone to gain control of the situation
Correct Answer: B
Rationale: The correct answer is B - Tell the client, 'You seem to be very upset.' This response shows empathy and acknowledgment of the client's emotions, which can help de-escalate the situation. It validates the client's feelings and opens the door for effective communication. Initiating seclusion protocol (A) may escalate the situation and should only be used as a last resort for safety. Standing directly in front of the client and maintaining eye contact (C) can be perceived as confrontational and may increase agitation. Speaking in a firm and authoritative tone (D) may further escalate the client's emotions. It is important to approach the situation with empathy and understanding to establish a therapeutic relationship.