Nokea
Which of the following attitudes is essential in a nurse who assists clients during crises?
- A. viewing crisis intervention as the first step in solving bigger problems
- B. wanting to help clients solve all problems identified
- C. taking an active role in guiding the process
- D. feeling that work requires identification with all of a client's problems
Correct Answer: A
Rationale: Viewing crisis intervention as the first step in solving bigger problems is essential in a nurse who assists clients during crises. Assessment of the present problem should be viewed as necessary. Time and limitations of crisis work need to be remembered. Complete diagnostic assessment is unnecessary, and unrelated material should not be explored. Referrals might be necessary for other identified problems.
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A woman asks, 'How much alcohol can I safely drink while pregnant?' The nurse's best response is:
- A. The amount of alcohol that is safe during pregnancy is unknown.'
- B. Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman.'
- C. Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy.'
- D. You can have a drink to help you relax and get to sleep at night.'
Correct Answer: A
Rationale: The amount of alcohol that is safe during pregnancy is unknown. Fetal alcohol syndrome is a combination of mental and physical abnormalities present in infants born to mothers who have consumed alcohol during pregnancy.
With a breech presentation, the nurse must be particularly alert for which of the following?
- A. quickening
- B. ophthalmia neonatorum
- C. pica
- D. prolapsed umbilical cord
Correct Answer: D
Rationale: Prolapsed umbilical cord is the descent of the umbilical cord into the vagina before the fetal presenting part and compression of the cord between the presenting part and the maternal pelvis, compromising or completely cutting off fetoplacental perfusion. This is an emergency situation; immediate delivery should be attempted to save the fetus.
A nurse gave medications to the wrong client. She stated the client responded to the name called. What is the nurse's appropriate documentation?
- A. Note in medication records the drug given
- B. The client was not hurt, no need for documentation
- C. Note the client's orientation
- D. Completely fill out an incident report
Correct Answer: D
Rationale: The incident report should always be filled out involving medication errors.
A nurse is instructing a person who had a left CVA and right lower extremity hemiparesis to use a quad cane. Which of the following is the most appropriate gait sequence?
- A. Place the cane in the patient's left upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
- B. Place the cane in the patient's left upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
- C. Place the cane in the patient's right upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
- D. Place the cane in the patient's right upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
Correct Answer: A
Rationale: The cane should be placed in the patient's strong upper extremity (left), and the sequence should coordinate the weak side (right leg) with the cane for support, followed by the strong side (left leg).
Support systems during the grieving process include all of the following except:
- A. a despondent friend.
- B. a nurse.
- C. a social worker.
- D. a family member.
Correct Answer: A
Rationale: A despondent friend, even though this could be a support to the grieving person, is in a state of despondency. Therefore, he or she might not do well with a grieving friend.