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What immediate intervention should a nurse provide for a hypoglycemic client?
- A. one commercially prepared glucose tablet
- B. two hard candies
- C. 4-6 ounces of fruit juice with sugar
- D. 2-3 teaspoons of honey
Correct Answer: C
Rationale: The correct immediate intervention for a hypoglycemic client is to provide 4-6 ounces of fruit juice with sugar. This is because the client needs a quick source of glucose to raise their blood sugar levels rapidly. Fruit juice with sugar is easily absorbed, providing a fast-acting solution to hypoglycemia. Commercially prepared glucose tablets may take longer to be absorbed than fruit juice. Hard candies and honey may not contain enough sugar to raise blood sugar levels quickly compared to fruit juice. Therefore, fruit juice with sugar is the most effective option for immediate intervention in hypoglycemic clients.
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A nurse is taking health history from a patient. The nurse observes the patient's nonverbal behaviors such as hand wringing, avoiding eye contact, and shifting in the seat. Which of the following would be an appropriate response by the nurse?
- A. Ask the patient to explain what they are feeling and what might have caused the behavior.
- B. Remain silent and allow the patient to continue at their own pace.
- C. Ask the patient if they feel nervous or worried about the pregnancy.
- D. Focus on making the patient feel heard and understood.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates empathy and addresses the patient's potential emotions directly. By asking if the patient feels nervous or worried about the pregnancy, the nurse acknowledges the observed nonverbal behaviors and opens the door for the patient to express their feelings. This approach shows sensitivity and may help the patient feel understood and supported.
Choice A is incorrect because directly asking the patient to explain what they are feeling might come off as intrusive and could make the patient uncomfortable. Choice B is not ideal as remaining silent may lead to missed opportunities for the patient to share their concerns. Choice D, while important, does not address the specific nonverbal cues observed and may not prompt the patient to open up about their emotions.
What does a comprehensive assessment include?
- A. Complete health history and physical exam
- B. Specific focus on a body system
- C. Emergency triage
- D. Specific assessment of client complaints
Correct Answer: A
Rationale: The correct answer is A because a comprehensive assessment involves gathering a complete health history and conducting a thorough physical examination to evaluate the client's overall health status. This includes assessing past medical history, family history, current medications, lifestyle factors, and performing a head-to-toe physical examination. This holistic approach helps in identifying any potential health issues or risk factors.
Choice B is incorrect because a specific focus on a body system is not comprehensive and may miss other important aspects of the client's health.
Choice C is incorrect as emergency triage is a rapid assessment to determine the severity of a medical condition and prioritize treatment, not a comprehensive assessment.
Choice D is incorrect because a specific assessment of client complaints is focused only on the reported issues and may not provide a comprehensive overview of the client's health.
Which of the following statements is a characteristic of the clinical practice guidelines for infants and children for a periodic health examination?
- A. They are used to diagnose an illness.
- B. They are helpful in identifying developmental delays in children.
- C. They recommend that every individual receive an annual physical examination.
- D. They list a frequency schedule for periodic health visits for a specific age group.
Correct Answer: D
Rationale: The correct answer is D because clinical practice guidelines for periodic health examinations provide a frequency schedule for health visits based on age. This is crucial for ensuring timely preventive care and monitoring of growth and development. Choice A is incorrect as guidelines focus on preventive care, not diagnosing illnesses. Choice B is incorrect because while guidelines may mention developmental milestones, their primary focus is on health maintenance. Choice C is incorrect as guidelines recommend health visits based on individual needs, not a one-size-fits-all annual physical examination.
A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which of the following would be an appropriate response by the nurse?
- A. "How does your family react to your pain?"
- B. "That must be terrible. You probably pinched a nerve."
- C. "I've had back pain myself, and I know it can be excruciating."
- D. "How would you say the pain affects your ability to carry on your daily activities?"
Correct Answer: D
Rationale: The correct answer is D because it focuses on assessing the impact of the pain on the woman's daily activities, which is crucial in understanding the severity and functional limitations caused by the pain. This helps in planning appropriate interventions and evaluating the effectiveness of treatment.
Choice A is incorrect as it shifts the focus to the family's reaction rather than the woman's pain. Choice B is incorrect as it assumes a diagnosis without proper assessment and may minimize the woman's experience. Choice C is incorrect as it redirects the conversation to the nurse's experience, which is not helpful in addressing the woman's pain and needs.
A nurse is providing education to a patient about managing hypertension. Which of the following statements by the patient indicates the need for further education?
- A. I will monitor my blood pressure regularly.
- B. I should take my medication at the same time each day.
- C. I will avoid eating high-sodium foods.
- D. I can stop taking my medication once my blood pressure returns to normal.
Correct Answer: D
Rationale: The correct answer is D because stopping medication once blood pressure returns to normal can lead to a relapse of hypertension. Step 1: Educate the patient that hypertension is a chronic condition requiring long-term management. Step 2: Explain the importance of continuing medication even when blood pressure is controlled. Step 3: Emphasize the risks of stopping medication abruptly. Other choices are incorrect because they promote positive behaviors for hypertension management: A: Monitoring blood pressure is essential. B: Taking medication consistently is crucial. C: Avoiding high-sodium foods helps control blood pressure.