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When resuscitation efforts are unsuccessful, which nursing action is most appropriate?
- A. Ask the parents for permission to perform an autopsy.
- B. Ask about the possibility of harvesting the infant's organs for transplantation.
- C. Check on the parents' choice for the funeral arrangements.
- D. Take the parents to a room where they can be with the baby.
Correct Answer: D
Rationale: Allowing parents to spend time with their deceased infant supports grieving and closure, prioritizing their emotional needs immediately after the loss.
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Which of the following identified assessment criteria is the highest priority for this client?
- A. The number of characteristics of the client's bowel movements
- B. How much the client knows about colostomy care
- C. Which coping mechanisms the client uses for handling stress
- D. The types of relationships the client has with peers
Correct Answer: A
Rationale: Monitoring bowel movements is critical in ulcerative colitis to assess disease activity and guide treatment, prioritizing physical health.
Which statement made by the client diagnosed with human immunodeficiency virus (HIV) would the nurse interpret as the most serious indication of an increased risk for suicide?
- A. I have been having recurring dreams about dying.
- B. How many people have died from HIV?
- C. Will I be alert when I'm near death?
- D. Everyone would be better off without me.
Correct Answer: D
Rationale: Expressing that others would be better off without them suggests feelings of worthlessness and hopelessness, strong indicators of suicidal ideation.
Which concept is most important for the nurse to convey to a client during a panic attack?
- A. The client is safe.
- B. The client is believed.
- C. The client is cared for.
- D. The client is accepted.
Correct Answer: A
Rationale: Reassuring safety addresses the client's fear, a core component of panic attacks, helping to de-escalate anxiety.
The 19-year old client regularly abuses dextromethorphan (DXM). Which activity if performed under the influence of dextromethorphan places the client at highest risk for complications related to DXM abuse?
- A. Dancing at a nightclub
- B. Competing in a swim meet
- C. Snow-skiing on spring break
- D. Fishing from a shaded shoreline
Correct Answer: A
Rationale: Dancing (A) risks hyperthermia with DXM. Swimming (B) skiing (C) and fishing (D) are cooler lower-risk activities.
Which action is most appropriate if the nurse discovers the oriented older couple having consensual sexual intercourse?
- A. Report it to their adult children.
- B. Restore a measure of privacy.
- C. Suggest they become roommates.
- D. Censure their sexual activity.
Correct Answer: B
Rationale: Restoring privacy respects the couple's autonomy and dignity, supporting their right to consensual intimacy.