Nokea
Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles?
- A. Implement firm but flexible boundaries in their relationship
- B. Encourage authoritative communication from the adult child
- C. Decrease socialization with extended relatives until roles are identified,
- D. Minimize open discussion regarding the changes to avoid embarrassment.
Correct Answer: A
Rationale: Boundaries foster healthy family dynamics during role adjustments.
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A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
- A. Document the client's behavior prior to being placed in seclusion,
- B. Assess the client's behavior once every hour
- C. Offer fluids every 2 hr.
- D. Discuss with the client his inappropriate behavior prior to seclusion
Correct Answer: A
Rationale: The correct answer is A: Document the client's behavior prior to being placed in seclusion. This is important for legal and clinical reasons as it provides a clear record of the client's behavior leading up to seclusion, ensuring transparency and accountability. Assessing behavior once every hour (choice B) may not be sufficient for monitoring the client's condition in seclusion. Offering fluids every 2 hours (choice C) is important for hydration but not directly related to seclusion. Discussing inappropriate behavior with the client (choice D) may escalate the situation and is not recommended in this scenario.
Which of the following medications should the nurse administer?
- A. Bisacodyl 10 mg rectal suppository
- B. Magnesium hydroxide 30 mL PO
- C. Famotidine 20 mg PO
- D. Loperamide 4 mg PO
Correct Answer: A
Rationale: The correct answer is A: Bisacodyl 10 mg rectal suppository. Bisacodyl is indicated for immediate relief of constipation as a rectal suppository. It acts directly on the colon to stimulate peristalsis and promote bowel movement. The rectal route ensures faster onset of action compared to oral medications, making it suitable for a patient needing immediate relief. Magnesium hydroxide (B) is a laxative taken orally, which may not provide quick relief. Famotidine (C) is for acid reflux, not constipation. Loperamide (D) is an antidiarrheal agent, not appropriate for constipation.
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 person
Correct Answer: B
Rationale: The correct answer is B: Initiate a discussion with clients about ways to cope with changes in family dynamics. This is the most appropriate strategy as it addresses the immediate impact of the suicide on family dynamics and helps clients develop coping mechanisms. Discussing coping strategies can empower clients to navigate the difficult changes they are facing.
A: Encouraging clients to establish a timeline for their own grieving process may not be helpful as each individual grieves differently and timelines can vary significantly.
C: Assisting clients in identifying ways suicide could have been prevented may lead to feelings of guilt and self-blame, which can be harmful to the healing process.
D: Discouraging clients from sharing negative aspects of their relationship with the deceased person can hinder the expression of emotions and the processing of complex feelings related to the loss.
The nurse should notify the provider for which of the following findings?
- A. Report of discomfort at the insertion site
- B. Heart rate 90/min
- C. Bounding pulses in the affected extremity
- D. Hematoma over the insertion site
Correct Answer: D
Rationale: The correct answer is D: Hematoma over the insertion site. This finding indicates potential internal bleeding, which can lead to complications. Notify the provider to assess and manage promptly. A: Discomfort at insertion site is common post-procedure and can be managed with appropriate interventions. B: Heart rate of 90/min is within normal range and does not require immediate provider notification. C: Bounding pulses in the affected extremity may indicate adequate perfusion and is not a concerning finding.
A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the cient's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?
- A. Fibrinogen level
- B. aPTT
- C. INR
- D. Platelet count
Correct Answer: C
Rationale: The correct answer is C: INR. The International Normalized Ratio (INR) is used to monitor and adjust the dosage of warfarin, an anticoagulant medication. A nurse needs to report the INR level to the provider to determine if the current dosage of warfarin is effective in preventing blood clots. A higher INR indicates a longer time it takes for blood to clot, meaning the warfarin dosage might need adjustment.
Incorrect choices:
A: Fibrinogen level - Fibrinogen is a protein involved in blood clotting but is not specific for monitoring warfarin therapy.
B: aPTT - Activated Partial Thromboplastin Time (aPTT) is used to monitor heparin therapy, not warfarin.
D: Platelet count - Platelet count measures the number of platelets in the blood and is not directly related to warfarin therapy.
Overall, the INR is the most