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Which of the following information should the nurse include?
- A. Information Technology will install a firewall to secure client information
- B. You will be asked to change your password once per year.
- C. Documentation of sensitive material is performed by the charge nurse.
- D. You will be given access to the medical records of every client in the facility.
Correct Answer: A
Rationale: Firewalls help protect sensitive client information in electronic health records.
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A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care?(Select all that apply.)
- A. Give the client one simple direction at a time
- B. Refute the client's delusions using logic
- C. Allow the client to choose among a variety of activities each day
- D. Reinforce orientation to time, place, and person
- E. Establish eye contact when communicating with the client.
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
A: Giving the client one simple direction at a time is essential for someone with dementia to reduce confusion and facilitate understanding.
D: Reinforcing orientation to time, place, and person helps maintain the client's sense of reality and reduce disorientation.
E: Establishing eye contact when communicating with the client enhances connection and understanding, aiding in effective communication.
Incorrect Choices:
B: Refuting the client's delusions using logic may lead to frustration and agitation, as individuals with dementia may not be able to understand or accept logical arguments.
C: Allowing the client to choose among a variety of activities each day may overwhelm them with choices, leading to increased confusion and agitation.
The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Chorioamnionitis
- B. Maternal fever
- C. Fetal anemia
- D. Maternal hypoglycemia
Correct Answer: D
Rationale: Maternal hypoglycemia can lead to fetal bradycardia.
Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?
- A. Amputation
- B. Osteoarthritis
- C. Hypertension
- D. Primary glaucoma
Correct Answer: C
Rationale: The correct answer is C: Hypertension. Hypertension is a contraindication to many medical procedures due to the increased risk of complications such as bleeding or cardiovascular events. In this case, performing a procedure on a child with hypertension could pose significant risks to their health. Amputation (A) is not necessarily a contraindication unless it directly affects the procedure site. Osteoarthritis (B) may not directly impact the procedure. Primary glaucoma (D) is not related to the procedure in question.
Which of the following statements should the nurse make?
- A. We can initiate medical care until you get legal assistance in preparing your advance directives.
- B. Advance directives can be signed without legal representation.
- C. Advance directives can be a verbal agreement between you and your provider until legal review can be obtained.
- D. A social worker will assist you to find affordable legal representation.
Correct Answer: B
Rationale: The correct answer is B: Advance directives can be signed without legal representation. This is correct because advance directives are legal documents that individuals can complete on their own without the need for a lawyer. They allow individuals to specify their healthcare wishes in advance. Choice A is incorrect as medical care can be initiated regardless of advance directives. Choice C is incorrect as advance directives must be in writing to be legally valid. Choice D is incorrect as social workers typically provide support but do not usually offer legal representation.
The nurse anticipates the client will likely require-------as evidenced by the client’s---------
- A. temperature
- B. stool test results
- C. respiratory rate
- D. an endoscopy
- E. an antifungal prescription
- F. oxygen via nonrebreather mask
Correct Answer: B,D
Rationale: The correct answers are B (stool test results) and D (an endoscopy). The nurse anticipates the client will likely require a stool test based on gastrointestinal symptoms, such as abdominal pain or blood in stool. Stool test results can help diagnose gastrointestinal issues. Additionally, the nurse may anticipate the need for an endoscopy to further investigate gastrointestinal symptoms, like persistent reflux or difficulty swallowing. Choices A, C, E, and F are less likely as they are not directly related to gastrointestinal issues. Choice E (antifungal prescription) may be relevant in case of fungal infection, but gastrointestinal symptoms would not typically prompt this. Choice F (oxygen via nonrebreather mask) is more related to respiratory issues.