Nokea
Which of the following is the most appropriate example of anticipatory guidance for a 16-year-old who has been hospitalized for an ankle fracture?
- A. Changes associated with puberty
- B. Driving and staying safe
- C. The health hazards of smoking
- D. Social media influences
Correct Answer: B
Rationale: The correct answer is B: Driving and staying safe. At 16, the teenager is likely preparing to start driving, so guidance on driving safety is crucial. An ankle fracture may impact their ability to drive safely. Other choices lack immediate relevance to the current situation. A: Puberty changes are important but may not be directly related to the hospitalization. C: Smoking hazards, while important, may not be a pressing concern during hospitalization. D: Social media influences, while relevant, are not as critical as driving safety in this scenario.
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At the beginning of the shift, a nurse receives report for her daily assignment. Which of the following situations should the nurse give first priority?
- A. A diabetic client with a blood glucose level of 195 mg/dL
- B. A family member of an elderly client who has questions
- C. A client with COPD with an oxygen saturation of 84%
- D. A client who requires assistance to use the bathroom
Correct Answer: C
Rationale: The correct answer is C: A client with COPD with an oxygen saturation of 84%. Oxygen saturation below 90% is considered critical, indicating hypoxemia in a client with COPD. Priority is given to critical physiological needs to avoid potential respiratory distress or failure. Choices A, B, and D are important but do not pose immediate life-threatening risks. The diabetic client with a blood glucose level of 195 mg/dL can be managed with insulin administration. The family member's questions can be addressed after addressing immediate client needs. The client who requires assistance to use the bathroom can be attended to once the critical client's needs are addressed. Prioritizing based on physiological urgency ensures client safety.
The nurse is performing discharge teaching for Mrs. S after cardiac angioplasty. Her husband is present for the teaching. While explaining the prescription for antiplatelet medication to use at home, Mrs. S's husband states, 'I don't think I can afford to refill that medication.' What is the most appropriate response of the nurse?
- A. Don't worry, your insurance will cover it.
- B. I'll ask the physician if he can prescribe a medication that is more affordable.
- C. You should apply for Medicare to see if they can help you.
- D. This medication is essential for her care and should be given priority over all others that she is taking.
Correct Answer: B
Rationale: The most appropriate response of the nurse is option B: "I'll ask the physician if he can prescribe a medication that is more affordable." This response demonstrates empathy towards the husband's concerns about affordability and shows willingness to explore alternative solutions. It acknowledges the financial constraint without making assumptions about insurance coverage or suggesting a specific program like Medicare. It also shows collaboration by involving the physician in finding a suitable alternative medication. The other choices are incorrect because they do not directly address the husband's affordability concern or offer a proactive solution to the issue.
The charge nurse is notified that the unit will be receiving an admission of a client from another bed in the hospital in order to make room for others being admitted through the emergency room. The unit is the Women's Health Center of the hospital. Which of the following patients would be most appropriate to be transferred to this unit?
- A. A 26-year-old woman who had a bowel resection
- B. A 40-year-old man who underwent a hernia repair
- C. A 31-year-old woman with septicemia and who is on a ventilator
- D. A 91-year-old man with Alzheimer's disease recovering from a fall
Correct Answer: A
Rationale: The correct answer is A: A 26-year-old woman who had a bowel resection. This choice is appropriate for the Women's Health Center as it aligns with the specialization of the unit in women's health. The patient's condition is surgical in nature, which can be managed effectively in a women's health unit that likely has the necessary resources and expertise to care for post-surgical patients.
Choice B: A 40-year-old man who underwent a hernia repair, is incorrect because it is not aligned with the specialization of the Women's Health Center.
Choice C: A 31-year-old woman with septicemia and on a ventilator, is incorrect because this patient requires intensive care and support beyond what a women's health unit can provide.
Choice D: A 91-year-old man with Alzheimer's disease recovering from a fall, is incorrect because this patient's needs are more aligned with geriatric care rather than women's health.
A client is found lying on the floor near the bathroom door, stating, 'I thought I could get up on my own.' What information must the nurse document in this situation?
- A. A statement explaining the condition the client was found in, quoting the client's words about the situation
- B. An explanation of how the fall happened and when the physician was notified
- C. An account of the conditions of the room that contributed to the client's fall
- D. A summary of the client's medical history and current medications
Correct Answer: A
Rationale: The correct answer is A because documenting the client's own words provides direct evidence of their condition and thought process at the time of the incident. This helps in understanding the client's perspective and decision-making, which is crucial for providing appropriate care and preventing future falls.
Choice B is incorrect because while it may be important to document how the fall happened and when the physician was notified, it does not directly capture the client's own words and thoughts.
Choice C is incorrect as it focuses on the conditions of the room rather than the client's own account of the situation.
Choice D is also incorrect as it pertains to the client's medical history and medications, which are important but not directly relevant to documenting the client's immediate situation and actions.
A nurse walks into a client's room to find the nursing assistant yelling, 'Sit back down or I won't help you eat, and then you will starve!' This type of behavior is known as:
- A. Psychological abuse
- B. Abandonment
- C. Material exploitation
- D. Physical abuse
Correct Answer: A
Rationale: The correct answer is A: Psychological abuse. This behavior involves verbal threats and emotional manipulation, causing fear and distress to the client. It violates the client's rights and dignity. Abandonment (B) refers to deserting a client in need. Material exploitation (C) involves misuse of a client's property or resources. Physical abuse (D) involves causing harm through physical force.