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When implementing a disaster intervention plan, which intervention should the nurse implement first?
- A. Initiate the discharge of stable clients from hospital units
- B. Identify a command center where activities are coordinated
- C. Assess community safety needs impacted by the disaster
- D. Instruct all essential off-duty personnel to report to the facility
Correct Answer: B
Rationale: When implementing a disaster intervention plan, the first step the nurse should take is to identify a command center where activities are coordinated. This step is crucial for ensuring an organized and effective disaster response. Option A, initiating the discharge of stable clients, is not a priority during the initial phase of disaster response. Option C, assessing community safety needs, usually follows setting up a command center. Option D, instructing off-duty personnel to report, may be necessary but is not the primary intervention at the beginning of a disaster situation.
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The nurse is planning care for a client with end-stage lung cancer. The client expresses concern about ongoing pain management. Which nursing action is most appropriate to include in the plan of care?
- A. Consult the healthcare provider for recommendations on pain management
- B. Schedule the client for physical therapy to manage pain
- C. Recommend the client attend a support group for cancer patients
- D. Suggest alternative therapies like acupuncture or massage
Correct Answer: A
Rationale: Consulting the healthcare provider for recommendations on pain management is the most appropriate action. The healthcare provider can assess the client's pain, prescribe appropriate medications, and adjust the pain management plan as needed. In end-stage cancer, managing pain often requires pharmacological interventions that the healthcare provider can best provide. Physical therapy (choice B) may not be the primary intervention for pain management in end-stage cancer. While attending a support group (choice C) can provide emotional support, it does not directly address the client's pain management concerns. Suggesting alternative therapies (choice D) is not the initial step; consulting the healthcare provider should come first to ensure a comprehensive and tailored pain management plan.
When assessing a client's blood pressure and determining an auscultatory gap, which action should the nurse implement?
- A. Compare the palpated systolic blood pressure with the auscultated pressure
- B. Assess the client for lightheadedness upon standing
- C. Determine if an automated blood pressure reading is consistent with the manual reading
- D. Observe for changes in blood pressure between lying and sitting positions
Correct Answer: A
Rationale: When an auscultatory gap is present, comparing the palpated systolic blood pressure with the auscultated pressure is crucial. This helps to accurately measure blood pressure and detect any discrepancies caused by the gap. Assessing for lightheadedness upon standing (choice B) is unrelated to addressing an auscultatory gap. Checking the consistency between automated and manual blood pressure readings (choice C) is important for validation but not specifically for managing an auscultatory gap. Observing blood pressure changes between lying and sitting positions (choice D) is relevant for orthostatic hypotension assessment but not for dealing with an auscultatory gap.
A man calls the hospital and asks to talk with the nurse about his girlfriend who was extremely intoxicated on admission and is receiving services for detoxification. He knows that she is in the facility and asks the nurse about her condition. What is the nurse's best response?
- A. ''I can only report that the client is in satisfactory condition.''
- B. ''Let me give you the telephone number for her room.''
- C. ''I cannot acknowledge if a client is here or not.''
- D. ''I will have the nurse who is working with her call you.''
Correct Answer: C
Rationale: The nurse must adhere to confidentiality rules and cannot confirm the presence or condition of the client. Choice A is incorrect because disclosing the client's condition breaches confidentiality. Choice B is wrong as it reveals the client's room number, which is also a breach of confidentiality. Choice D is not the best response as it involves sharing information about the client without verifying the caller's identity or relationship to the client.
An adolescent male client is admitted to the hospital. Based on Erikson's theory of psychosocial development, which nursing intervention best assists this adolescent's adjustment to his hospital stay?
- A. Invite him to participate in the evening group activity
- B. Schedule frequent private phone calls to his parents
- C. Provide access to a variety of video games in his room
- D. Encourage him to learn his way around the hospital
Correct Answer: A
Rationale: Inviting the adolescent to participate in group activities aligns with Erikson's theory of psychosocial development, specifically the stage of developing social relationships. By engaging in group activities, the adolescent can interact with peers, fostering social skills and aiding in adjustment to the hospital environment.
Choice B is incorrect as excessive reliance on phone calls to parents may hinder the adolescent's autonomy and independence, which are crucial aspects of Erikson's theory for this age group. Choice C, providing access to video games, while potentially offering entertainment, does not directly address the need for social interaction and relationship-building. Choice D, encouraging the adolescent to learn his way around the hospital, is important for familiarity but may not directly address the need for social interaction and adjustment in the hospital setting.
The nurse has explained safety precautions and infant care to a primigravida mother and observes the mother as she gives care to her newborn during the first two days of rooming-in. Which action indicates the mother understands the instruction?
- A. Aspirates the newborn's nares using a syringe
- B. Applies a dressing to the cord after the newborn's bath
- C. Breastfeeds the infant every hour during the night
- D. Positions the infant supine in the crib to sleep
Correct Answer: D
Rationale: Positioning the infant supine in the crib to sleep is the correct action that indicates the mother understands the instruction. This position is recommended to reduce the risk of Sudden Infant Death Syndrome (SIDS). Choice A is incorrect as it is not a routine or recommended practice to aspirate the newborn's nares using a syringe without a specific medical indication. Choice B is incorrect because applying a dressing to the cord after the newborn's bath is not a standard care practice. Choice C is incorrect because breastfeeding every hour during the night is excessive and not a recommended feeding schedule for a newborn.