Nokea
The nurse should notify the provider for which of the following findings?
- A. Report of discomfort at the insertion site
- B. Heart rate 90/min
- C. Bounding pulses in the affected extremity
- D. Hematoma over the insertion site
Correct Answer: D
Rationale: The correct answer is D: Hematoma over the insertion site. This finding indicates potential internal bleeding, which can lead to complications. Notify the provider to assess and manage promptly. A: Discomfort at insertion site is common post-procedure and can be managed with appropriate interventions. B: Heart rate of 90/min is within normal range and does not require immediate provider notification. C: Bounding pulses in the affected extremity may indicate adequate perfusion and is not a concerning finding.
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Which of the following actions should the nurse plan to take?
- A. Launch a media campaign to increase awareness about industrial pollution
- B. Have a nurse from outside the community provide health lectures at the county hospital
- C. Encourage rural residents to focus health spending on tertiary health interventions
- D. Provide anticipatory guidance classes to parents through public schools
Correct Answer: D
Rationale: The correct answer is D because providing anticipatory guidance classes to parents through public schools is a proactive approach to promote health and prevent illness in the community. This action empowers parents with knowledge and skills to make informed health decisions for their children. Launching a media campaign (A) may raise awareness but may not directly impact individual behavior change. Having a nurse from outside the community provide health lectures (B) may not be as effective as someone familiar with the community's specific needs. Encouraging rural residents to focus on tertiary health interventions (C) is reactive and may not address prevention.
Which of the following actions should the nurse take?
- A. Refer the adolescent to a local mental health clinic.
- B. Advise the adolescent to place the newborn for adoption
- C. Contact the adolescent's parent for assistance
- D. Assist the adolescent in applying for Medicaid
Correct Answer: D
Rationale: Medicaid can provide financial assistance for prenatal care and delivery.
A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?
- A. Speak slowly when talking to the interpreter.
- B. Pause in the middle of sentences
- C. Speak directly to the client
- D. Use gestures to convey meaning
Correct Answer: C
Rationale: The correct answer is C: Speak directly to the client. This is important because even when using an interpreter, the nurse should maintain eye contact and address the client directly to establish trust and ensure the message is accurately conveyed. Speaking slowly (choice A) may be helpful, but it is not as crucial as direct communication. Pausing in the middle of sentences (choice B) could lead to confusion. Using gestures (choice D) may not always accurately convey the intended message. Therefore, speaking directly to the client is the most effective way to ensure clear communication and understanding.
Which of the following responses should the nurse make?
- A. Are you not happy with your treatment?
- B. We can provide a copy of your records, but the therapist's notes are not included.
- C. Why are you interested in seeing your therapist's notes?
- D. I don't think you will benefit from reviewing your therapist's notes right now.
Correct Answer: B
Rationale: The correct response is B: "We can provide a copy of your records, but the therapist's notes are not included." This answer respects the patient's request for records while also maintaining confidentiality of the therapist's notes. Offering a copy of the records shows transparency and willingness to provide information to the patient. Choices A, C, and D are incorrect because they do not address the patient's request appropriately - A assumes dissatisfaction, C questions the patient's motive, and D dismisses the request without explanation.
Which of the following information should the nurse include?
- A. This type of seizure lasts 30 to 60 seconds.
- B. This type of seizure can be mistaken for daydreaming.
- C. This type of seizure has a gradual onset.
- D. The child usually has an aura prior to onset.
Correct Answer: B
Rationale: Absence seizures are often brief and can easily be mistaken for daydreaming.