Nokea
What must be the priority consideration for nurses when communicating with children?
- A. Present environment
- B. Physical condition
- C. Nonverbal cues
- D. Developmental level
Correct Answer: D
Rationale: While each of the factors affects communication, the nurse recognizes that developmental differences have implications for processing and understanding information. Consequently, a child's developmental level must be considered when selecting communication approaches.
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To prevent symptoms of Raynaud's, the client should:
- A. Avoid a high-sodium diet
- B. Take a brisk, 15-minute walk daily
- C. Avoid exposure to cold
- D. Increase her vitamin C intake
Correct Answer: C
Rationale: Avoiding cold exposure is key to preventing vasospasms in Raynaud's disease, which cause symptoms like numbness and color changes in the extremities.
Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take?
- A. Record the information on the chart
- B. Give information about advance directives
- C. Assume that this client wishes a full code
- D. Refer this issue to the unit secretary
Correct Answer: B
Rationale: For each admission, nurses should request a copy of the current advance directive. If there is none, the nurse must offer information about what an advance directive implies. It is then the client's choice to sign it.
A woman who recently had a simple mastectomy is about to be discharged. She seems very concerned about such things as where to find the best prosthesis, suitable underwear, and swimsuits, and adjusting to life with only one breast. Which resource is appropriate for the nurse to recommend?
- A. A psychologist or psychiatrist
- B. Reach to Recovery
- C. Pastoral counseling
- D. Her physician
Correct Answer: B
Rationale: Reach to Recovery offers peer support and resources for mastectomy patients, addressing prosthesis and lifestyle adjustments. Other options are less specific.
The nurse is teaching the client with an ileal conduit regarding skin care to prevent excoriation. In addition to applying a well-fitted collection bag the client should be told to empty the collection bag:
- A. Every hour
- B. When it is half full
- C. Once daily
- D. When it is one-third full
Correct Answer: D
Rationale: The client should be told to empty the collection bag when it is one-third full. Answer A isn't necessary or feasible, so it is incorrect. Waiting until the collection bag is half full or more as suggested in answers B and C increases the likelihood of skin exposure to urine thereby contributing to excoriation.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving oxygen at 2 L/min via nasal cannula. Which of the following findings would be of GREATest concern to the nurse?
- A. Oxygen saturation of 90%.
- B. Respiratory rate of 20 breaths/min.
- C. Temperature of 101°F (38.3°C).
- D. Heart rate of 80 bpm.
Correct Answer: C
Rationale: A temperature of 101°F suggests infection, a serious complication in COPD that can exacerbate respiratory distress. Options A, B, and D are acceptable: oxygen saturation 90% is adequate for COPD, respiratory rate 20 is normal, and heart rate 80 bpm is normal.