Nokea
What stressors is she experiencing (select all that apply)?
- A. Change in role within the family
- B. Lack of respite from caregiving responsibilities
- C. Conflict in the family related to decisions about caregiving
- D. Financial depletion of resources as a result of her inability to work
Correct Answer: C
Rationale: The correct answers are all listed. Each option represents a potential stressor experienced by the caregiver due to her father's condition and the dynamics within her family.
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Which term describes a nurse’s inability to differentiate between the beliefs of clients in the same culture?
- A. Generalization
- B. Stereotyping
- C. Ethnocentrism
- D. Cultural imposition
Correct Answer: B
Rationale: Stereotyping involves oversimplifying and applying generalized beliefs to individuals within a culture, hindering effective care.
A patient in heroin withdrawal comes to the nurse's station demanding a narcotic saying he or she is going to die from the withdrawal. The patient received detox medication 30 minutes ago. What is the best response?
- A. Call a rapid response before the patient has a seizure.
- B. Tell the patient he or she is not going to die from opioid withdrawal and that you will see if he or she has any PRN medications available.
- C. Tell the patient to speak with the practitioner in the morning.
- D. Tell the patient that you will call the practitioner now to see if the practitioner will order a narcotic.
Correct Answer: B
Rationale: Reassurance and checking for available PRN medications address both the patient's anxiety and potential need for additional symptom management.
When prioritizing client care after receiving change-of-shift report, which of the following clients should the nurse plan to see first?
- A. A client who is scheduled for an abdominal x-ray and is awaiting transport
- B. A client who has a prescription for discharge
- C. A client who received oral pain medication 30 minutes ago
- D. A client who told an assistive personnel he is short of breath
Correct Answer: D
Rationale: The correct answer is D because a client who is experiencing shortness of breath may be in a critical condition requiring immediate intervention to prevent respiratory distress or failure. This is a high-priority issue that needs prompt assessment and intervention to ensure the client's safety.
A: A client awaiting transport for an abdominal x-ray is not in an immediate life-threatening situation.
B: A client with a prescription for discharge can typically wait as the discharge process can be coordinated by other healthcare team members.
C: A client who received oral pain medication 30 minutes ago is not experiencing an urgent or life-threatening situation, as the medication may take time to alleviate pain.
A client returns to the Cardiovascular Intensive Care Unit following a coronary artery bypass graft (CABG). In planning the client's care, the most important electrolyte to monitor is:
- A. chloride.
- B. bicarbonate.
- C. potassium.
- D. sodium.
Correct Answer: C
Rationale: Chloride, bicarbonate, and sodium will need to be monitored, but they are not as important as potassium. Potassium will need to be closely monitored, because of its effects on the heart. Hypokalemia could result in supraventricular tachyarrhythmias.
Which of the following describes task-oriented touch?
- A. It is used to demonstrate concern or affection.
- B. It involves the contact required for nursing procedures.
- C. The nurse uses task-oriented touch therapeutically when a client is lonesome.
- D. It involves the touch used for sensory-deprived clients.
Correct Answer: B
Rationale: Task-oriented touch is necessary for performing nursing procedures and ensuring client safety.