Nokea
A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?
- A. Hypertension
- B. Fibromyalgia
- C. Renal calculi
- D. Fibrocystic breast disease.
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Hypertension is a contraindication to combination oral contraceptive use due to the increased risk of cardiovascular events. The estrogen component in oral contraceptives can further elevate blood pressure, leading to complications. Other choices like B: Fibromyalgia, C: Renal calculi, and D: Fibrocystic breast disease are not contraindications for oral contraceptive use. Fibromyalgia is a chronic pain condition unrelated to oral contraceptives. Renal calculi are kidney stones, which do not directly affect the safety of oral contraceptives. Fibrocystic breast disease is a benign condition and not a contraindication to oral contraceptives.
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A nurse is preparing to administer a medication that is available in a glass ampule. Which of the following actions should the nurse plan to take?
- A. The nurse should use a filter needle to withdraw the medication.
- B. The nurse should break the neck of the ampule toward their body.
- C. The nurse should use the same needle to draw up and inject the client.
- D. The nurse should dispose of the ampule in the trash can.
Correct Answer: A
Rationale: The correct answer is A. Using a filter needle to withdraw the medication from a glass ampule helps prevent glass particles from contaminating the medication. Breaking the neck of the ampule toward the body (choice B) can lead to injury. Using the same needle to draw up and inject the client (choice C) increases the risk of contamination. Disposing of the ampule in the trash can (choice D) without following proper disposal protocols can be hazardous.
A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
- A. Instruct the client to lift her chin when swallowing.
- B. Talk with the client during her feeding.
- C. Sit at or below the client's eye level during feedings.
- D. Discourage the client from coughing during feedings.
Correct Answer: C
Rationale: The correct answer is C: Sit at or below the client's eye level during feedings. This position helps promote proper swallowing mechanics and reduces the risk of aspiration in clients with dysphagia. Sitting at or below eye level encourages proper head positioning and coordination during swallowing. Choices A and B are incorrect as they do not directly address the physical positioning needed for safe feeding. Choice D is incorrect as coughing during feedings can help prevent aspiration.
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?
- A. I think I should take my pain medication more often, since it is not controlling my pain.
- B. Breathing faster will help me keep my mind off of the pain.
- C. It might help me to listen to music while trying to sleep.
- D. I don't want to walk today because I have some pain.
Correct Answer: C
Rationale: The correct answer is C: "It might help me to listen to music while trying to sleep." This answer indicates that the client understands the preoperative teaching about pain management, as distraction techniques such as listening to music can help manage pain perception. Listening to music can be a non-pharmacological method to alleviate pain and promote relaxation. Choices A and D indicate a lack of understanding as they suggest inappropriate responses to pain. Choice B suggests a distraction technique but not the most effective one. Choices E, F, and G are not provided, but based on the context, they would likely be irrelevant or incorrect in the context of pain management.
A nurse is caring for a client who is immobilized. Which of the following interventions is appropriate to prevent contracture?
- A. Position a pillow under the client's knees.
- B. Place a towel roll under the client's neck.
- C. Align a trochanter wedge between the client's legs.
- D. Apply an orthotic to the client's foot.
Correct Answer: D
Rationale: The correct answer is D: Apply an orthotic to the client's foot. Contractures are a common complication in immobilized clients, where muscles and tendons shorten and tighten due to lack of movement. Applying an orthotic to the foot helps maintain proper alignment and prevents the foot from being in a fixed position, thus reducing the risk of contractures. Positioning a pillow under the client's knees (A) may help with comfort but does not directly prevent contractures. Placing a towel roll under the client's neck (B) is unrelated to preventing contractures in the lower extremities. Aligning a trochanter wedge between the client's legs (C) is more for hip alignment and may not directly prevent contractures in the foot.
A parish nurse is leading a support group for clients whose family members have committed suicide. Which of the following strategies should the nurse plan to use during the group session?
- A. Encourage clients to establish a timeline for their own grieving process.
- B. Initiate a discussion with clients about ways to cope with changes in family dynamics.
- C. Assist clients in identifying ways suicide could have been prevented.
- D. Discourage clients from sharing negative aspects of their relationship with the deceased persons.
Correct Answer: B
Rationale: The correct answer is B: Initiate a discussion with clients about ways to cope with changes in family dynamics. This strategy is important in supporting clients dealing with the aftermath of a family member's suicide as it acknowledges the significant impact on family dynamics. It allows clients to explore and process the changes within the family system and develop coping mechanisms. This approach fosters open communication and mutual support within the group.
Choice A is incorrect because grief is a highly individualized process and establishing a timeline may not be helpful or realistic for everyone. Choice C is incorrect as it may inadvertently place blame on the deceased and lead to feelings of guilt among clients. Choice D is incorrect as it can hinder the healing process by suppressing valid emotions and preventing the group from exploring their feelings openly.