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A community health nurse is working with a family that is struggling to adapt following the loss of a family member.
Which of the following actions should the nurse take first?
- A. Encourage the family to assign specific tasks to individual family members.
- B. Determine the roles of individual family members.
- C. Assist the family to establish a daily routine
- D. Refer the family to a grief support group.
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This is the first step because it helps identify the strengths and abilities of each family member, allowing for effective delegation of tasks and responsibilities. By understanding each member's role, the nurse can promote a balanced distribution of duties and enhance the family's ability to cope with the situation. Encouraging the family to assign specific tasks (A) may be premature without knowing each member's capabilities. Establishing a daily routine (C) can come after roles are determined to provide structure. Referring to a grief support group (D) may be necessary but not the first step.
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A nurse is planning care for a client who sustained a major burn over 20% of the body.
Which of the following interventions should the nurse include to support the client's nutritional requirements?
- A. Keep a calorie count for foods and beverages
- B. Provide a high-calorie, high-protein diet
- C. Encourage a low-fat diet to prevent digestive issues
- D. Restrict oral intake and provide IV fluids only
Correct Answer: B
Rationale: The correct answer is B: Provide a high-calorie, high-protein diet. This intervention supports the client's nutritional requirements by ensuring they receive adequate energy and protein for healing and overall health. High-calorie intake can prevent malnutrition, while high-protein intake supports tissue repair and immune function. Keeping a calorie count (A) is helpful but not as crucial as ensuring the client receives enough calories and protein. Encouraging a low-fat diet (C) is not the priority when aiming to meet nutritional requirements. Restricting oral intake (D) and providing IV fluids only can lead to malnutrition and should be avoided.
A nurse in an antepartum unit is caring for a client.
Nurses' Notes
2000:
Client is 38-year-old, G4 P3 at 38 weeks of gestation. Presents for evaluation of labor and
spontaneous rupture of membranes (SROM). Client states, "My water broke a couple of hours
ago and is a greenish color," Client also reports contractions began about 4 hr. ago and have
become consistently stronger and closer together.
Electronic fetal monitor applied. Small amount of thin green fluid noted on perineal pad.
Contraction palpated, lasted 40 seconds, moderate in intensity. Fetal heart rate (FHR) 165/min.
Vaginal examination performed: cervix 4 cm dilated, 70% effaced, 0 station, vertex presentation.
Client reports a history of chronic hypertension that has been well-controlled during this
pregnancy. Also states was diagnosed with gestational diabetes at 28 weeks of gestation.
2020:
Contractions occurring every 4 to 5 min, lasting 40 to 60 seconds. Small amount of bloody show
noted when changing disposable pad on bed. Client rates contraction pain as a 5 on a scale of 0
to 10, breathing well through contractions., FHR 168/min, minimal variability. Client denies
epigastric pain or visual disturbances. Trace of edema noted to bilateral lower extremities
The nurse should first notify the provider about------- followed by the-----------
- A. the fetal station and presentation
- B. frequency of uterine contractions
- C. green color of amniotic fluid
- D. history of gestational diabetes
- E. cervical dilation of 4 cm
Correct Answer: C
Rationale: The green color of amniotic fluid indicates meconium-stained fluid which can be a sign of fetal distress.
Nurses' Notes
Day 1, 0915:
The client's adult child reports the client has not slept for 2 days and has become obsessed with
cleaning the house and hosting parties. At times the client is overly joyous and has a very
elevated sense of self-confidence. The adult child states that the client has also demonstrated
very impulsive spending habits and expresses concern about the client giving away large sums
of money to others.
The client's speech is very pressured, disorganized, and loud. Client unable to recall the last time
they ate.
Day 1, 0930:
Client questioned about their hallucinations and states that the same person has been following
them around inside and outside the house for days. Client asks the person what they want but
never receives an answer, Client states that this person has never told them to do anything: they
just stare and smile.
For each assessment finding, click to specify if the finding is consistent with psychosis or mania.
- A. Hallucinations
- B. Lack of sleep
- C. Excessive spending habits
- D. Disorganized thought process
- E. Pressured speech
Correct Answer: A,B,C,D,E
Rationale: The correct answer is A, B, C, D, E. Hallucinations, lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are all consistent with both psychosis and mania. Hallucinations are sensory perceptions without a real external stimulus, common in both conditions. Lack of sleep is a hallmark symptom of mania and can also exacerbate psychotic symptoms. Excessive spending habits are often seen in manic episodes due to impulsivity, and disorganized thought process and pressured speech are characteristic of both psychosis and mania, reflecting the underlying cognitive and communication disturbances. Other choices are not specific or commonly associated with psychosis or mania.
A nurse is caring for a client in the active phase of labor who has decided to have a natural childbirth.
Which pain management technique should the nurse suggest?
- A. Provide information about the use of hydrotherapy during labor
- B. Encourage the use of breathing techniques to manage pain.
- C. Suggest the use of massage or counterpressure to relieve discomfort.
- D. Recommend positioning changes, such as walking or rocking, to ease pain.
- E. Support the use of relaxation techniques, such as visualization, to reduce stress.
Correct Answer: B
Rationale: The correct answer is B: Encourage the use of breathing techniques to manage pain. Breathing techniques help in pain management by promoting relaxation, reducing anxiety, and increasing oxygen flow. This can help the laboring individual cope better with contractions. Other choices are less effective for pain management in labor. A: Hydrotherapy can be beneficial, but breathing techniques are more universally applicable. C: Massage and counterpressure can help, but may not be as effective as breathing techniques during labor. D: Positioning changes are helpful, but breathing techniques are more directly focused on pain management. E: Relaxation techniques like visualization are useful, but breathing techniques are more specifically targeted at managing pain.
A nurse is caring for a client who is receiving radiation therapy and is experiencing anorexia.
Which of the following actions should the nurse take?
- A. Provide the client with cold foods rather than hot foods
- B. Encourage the client to drink fluids with meals
- C. Offer the client large meals three times a day
- D. Advise the client to avoid high-protein foods
Correct Answer: A
Rationale: The correct answer is A because providing the client with cold foods rather than hot foods can help reduce nausea and vomiting, which are common symptoms of pregnancy. Cold foods are generally better tolerated by pregnant women experiencing morning sickness. Encouraging the client to drink fluids with meals (choice B) is important, but it is not the most immediate action to alleviate nausea. Offering the client large meals three times a day (choice C) may worsen nausea, as smaller, more frequent meals are typically recommended. Advising the client to avoid high-protein foods (choice D) is not necessary unless there are specific contraindications, as protein is important for fetal development.