PrepU Q's to learn from!
The nurse is performing an admission assessment of a new client. When asked about the use of herbs and supplements, the client states, "Just valerian for the past few weeks." What nursing actions are appropriate? Select all that apply.
Selected: -Ensure that the client's ordered blood tests include liver enzymes. -Assess the client for recent anxiety or insomnia. -Ensure that the care provider is made aware of the client's use of valerian. -Assess for a history of recreational drug use. Answers: -Assess the client for recent anxiety or insomnia. -Ensure that the care provider is made aware of the client's use of valerian. Rationale: Valerian is an herb that is often used to treat anxiety or insomnia. It is not used to treat nausea or loss of appetite. There is no direct risk of hepatotoxicity associated with valerian, and it is not frequently abused. As with all herbs, the care provider must be made aware of the client's use.
When the client is involuntarily committed to a hospital because the client is assessed as being dangerous to himself or others, which client rights are lost?
Selected: freedom from seclusion and restraints Correct: the right to leave the hospital against medical advice Explanation: When a client is committed involuntarily, the right to leave against medical advice is forfeited. All the other rights are preserved unless there is further court action or a case of imminent danger to self or others (hitting staff, cutting self).
A client is scheduled to have an elective mandibular osteotomy to correct a mandibular fracture sustained in an accident 6 months earlier. Which statement by the client indicates to the nurse that the client is having difficulty coping?
Selected: "My wife will help me, but I don't think I'll need that much help." Answer: "I'll be glad to have my jaw fixed because my wife thinks I don't look like myself." Rationale:A client should not elect surgery to meet someone else's needs. The nurse should encourage the client to share his feelings and his perception of the deformity and to clarify his reasons for electing to have the surgery. It is normal to be somewhat afraid, and it is good if a client says he feels "OK" about the surgery. The fact that a client believes that his wife will help him after surgery and that he will also be relatively independent reflects appropriate adaptation. It is a common feeling among preoperative clients that they are ready to "get this over with," indicating that the waiting period is stressful
A preschool-age child presents to the emergency department. His father tearfully reports that his son was on his shoulders in the driveway playing when he began to fall. When the child began to fall, the father grabbed him by the leg, swinging him toward the grass to avoid landing on the pavement. As the father swung his son, the child hit his head on the driveway and twisted his right leg. After a complete examination, it is determined that the child has a skull fracture and a spiral fracture of the femur. Which action should the nurse take?
Selected: Notify the police immediately. Correct: Record the father's story in the medical record. Explanation: The father's story is consistent with the injuries incurred by the child; therefore, the nurse should document the cause of injury. There is no need to restrict the father's visitation because the injuries sustained by the child are consistent with the explanation given. The police only need to be notified if there is suspicion of child abuse. The injuries incurred by this child appear to be accidental. There is no need to refer the father for parenting classes. The father appears to be upset about the accident and will not likely repeat such reckless behavior. However, the nurse should educate the father regarding child safety.
An elderly Jewish client received a lunch tray that consists of a cheeseburger, French fries, and an apple. The client tells the nurse to remove the tray. What is the nurse's understanding of why the client wants the tray removed?
Answer: Clients of the Jewish faith do not allow the mixture of dairy and meat. Rationale: Clients of the Jewish faith do not allow the mixture of dairy and meat, and this should be respected by the nurse. Meat is permitted at any time of the day. There are not special dietary issues related to fruit. Client's families cannot be involved in meal preparations and decisions.
A client who has been using benzodiazepines for anxiety wants to add an alternative therapy. The nurse suggests biofeedback. How will the nurse best describe biofeedback to the client?
Answer: It is a way to concentrate on the body's response during a stressful situation. Rationale: Biofeedback uses the senses such as heart rate and respiratory rate to sensitize the client to ways to find calm. The client uses the responses of the body to relax. This therapy can assist the client in finding alternative ways to deal with stressors. Rather than controlling emotions, biofeedback allows the person to recognize and respond to physical signs of emotional stress before the emotions are fully formed. When biofeedback is not effective or is still being learned, antianxiety medications are useful; however, biofeedback works well alone. This therapy does not balance energies.
After unsuccessful CPR efforts, the nurse must prepare an Islamic client for the morgue. Which nursing action should the nurse take?
Answer: asking the client's family if they want to perform the ritualistic washing Rationale: -Physical care, at death, for a person of the Islamic faith consists of ritualistic washing by the family, with the client's body positioned toward Mecca. This action would be a family choice. -The Burial Society may perform ritual cleansing for clients of the Jewish faith. -Hindu clients believe that only family and close friends should touch the body. -Routine post-mortem care is appropriate for Christian clients.
A client reports nausea unrelieved by a recent antiemetic dose. The client asks for another treatment for the nausea. What is an alternative therapy to treat nausea?
Answer: ginger Rationale: -Ginger is an alternative therapy to aid in the treatment of nausea. -Kava is used for the treatment of anxiety and stress. --Raspberry aids in healing of minor wounds. -Red clover is used as an estrogen replacement in menopause.
An alert and oriented client refuses chemotherapy. The client's family believes that the client should receive it. Which is the nurse's best response to the client?
Selected: "How does your family feel about your decision?" Answer: "You understand that this decision is ultimately yours to make." Rationale: A competent client has the right to refuse care. The role of the nurse is to advocate for the client and respect the client's decision. In that role, it is essential for the nurse to make sure that the client is informed regarding the outcome of any choices made. The nurse should not offer advice or attempt to influence the client with personal beliefs or family influence. I picked that answer bc I thought that it would be best to assess family dynamics. Plus the right answer was more of a direct statement rather than asking if the pt understood their rights.
The healthcare provider has indicated that a client has a poor prognosis for recovery, and the family is very concerned. How would the nurse best support the family?
Selected: Reassure the family that it is normal to feel concerned after hearing such a prognosis. Answer: Accommodate their grieving, explain what is happening, and encourage involvement in the care. Explanation: -The family is grieving, and it is important to acknowledge and listen to them. They need to know what is happening. They also need to be encouraged to be involved in the client's care to give them an opportunity to connect and feel actively involved. -It is difficult for them to give up hope and be realistic regarding the prognosis; they need to have time. -Reassuring the family that it is normal to feel concerned is not therapeutic. -Encouraging the family to stay positive is not realistic at this time.
A young Middle Eastern woman's father and brother arrive at the hospital to learn that the physician arrived early and discussed the results of the client's skin biopsy directly with her. They become agitated and begin yelling. The best action for the nurse to take is to:
Answer: ask the the father and brother if they would like the physician to meet with the family Rationale: The best action for the nurse is to recognize that in some cultures the male members of the family are very protective of female members and to respect their cultural expectations. In this case they are apt to perceive the physician as having acted disrespectfully by not communicating directly with them. In this case the nurse should alert the physician to establish his availability and communicate this to the client's father and brother. It may not be helpful to offer to review the information with them. It is inappropriate to call security or to initiate a psychiatric emergency at this time. (I got it right but thought that calling the physician to speak w/ the dad + bro might violate pt privacy. But in this case it doesn't bc they're going to discuss respect , not private info).
The nurse is teaching a group of high school students about risk-taking behaviors. Which topic would be considered an example of healthy behaviors?
Answer: preventative vaccinations Explanation: Preventative vaccinations are not associated with a risk-taking behavior. Vaccinations are used as vehicles to prevent communicable diseases rather than living dangerously. The other choices are all associated with risk-taking behaviors: smoking, drinking, and motor vehicle accidents. These are especially important to discuss with young adults. The "responsible drinking habits" threw me off bc it had the word responsible in it. But I realize, these are HIGH SCHOOL students and underage.
A client with chronic pain comes to the clinic for an evaluation. During the visit, the client asks the nurse about possibly using acupuncture for pain relief. Which response by the nurse would be most appropriate?
Selected: "Acupuncture is effective for acute pain but not chronic pain" Answer: "Restoring the energy balance in your body could help with pain relief." Rationale: Acupuncture is a complementary therapy used for a wide range of conditions, including acute and chronic pain. It addresses a person's qi, either increasing or decreasing the flow of qi, restoring the balance of energy (yin and yang) in the body. This change in flow is believed to contribute to healing. Although the therapy requires the person to lie still for a period of time, it does not require the person to assume different positions during that time. Another answer says that it releases endorphins, which leads to flow of qi?
A nurse working on a medical unit is caring for a client with anemia. The nurse has a part-time business selling vitamin supplements. The nurse approaches the client, offering to sell the supplements to help "improve your blood." A second nurse overhears the conversation. How should the second nurse address this situation?
Selected: Report the nurse to the nurse manager and the nursing regulatory body. Correct: Inform the nurse that selling supplements to clients is a conflict of interest. Explanation: The first nurse is offering advice outside the scope of practice for an RN and could be accused of diagnosing and prescribing. The nurse is also working outside the therapeutic relationship. The client may feel pressured to purchase the supplements to get nursing care or further assistance from the nurse, which puts the nurse in a position of power over the client. It is not appropriate to tell the client to not purchase supplements from the nurse. It is also not appropriate to interview the nurse's other clients. Finally, as a professional, the second nurse should address the behavior with the colleague first and provide a teaching opportunity. If the first nurse does not agree to stop, or is found engaging in the behavior again, then reporting to the manager and regulatory body is appropriate. Sooo when do you confront the nurse first vs speak to the nurse manager first??
An Orthodox Jewish pregnant woman comes to the labor and birth suite with her birth attendant. Her partner is also present in the room. The woman is about to give birth when the nurse observes the partner move to the head of the bed outside the view of the birth. The nurse interprets this action as:
Selected: reflecting the cultural position of the husband as the head of the house. Answer: reflecting of the couple's religious beliefs and practices. Rationale: In the Orthodox Jewish faith, a lack of physical contact between the husband and wife during labor and birth is a religious practice. Additionally, the husband will stand in a place where the birth cannot be seen or a drape will be placed for the delivery so that he cannot view the birth. The husband's movement away from the wife does not demonstrate a lack of interest, the husband's anxiety, or the husband's role in the family as head of the household.
A client was brought to the hospital in an agitated state and admitted to a psychiatric unit for observation and treatment. On admission, the client was found to be talking rapidly and folding and unfolding garments several times while putting personal belongings away. The client is unable to settle down. Which assessment of the client would have highest priority at this time?
Selection: barriers to effective communication Correct response: feelings of anxiety Rationale: Anxiety is the top priority at this time. The client is exhibiting behavior that is indicative of anxiety, including restlessness, irritability, rapid speech, and inability to complete tasks. The other aspects of the nursing assessment are significant, but are not the top priority. I picked communication barriers bc I thought that the client was dissociating + not being able to communicate w/ the nurse.
Nurses are aware that culture links a wide variety of behaviors and events uniquely. For Westerners, which is a culturally linked behavior to autopsy?
Selected: the cause of death can be discovered Correct: the cause of death can be discovered Explanation: -Westerners believe that autopsy is used to discover the causes of death. -Hmong who have not converted to Christianity believe that autopsy prevents continuation of society and rebirth. -Judeo-Christians believe that the body ultimately decomposes into dust.
A nurse is caring for a middle-aged client who has undergone hemicolectomy for colon cancer. The client has two children. Which concepts about family would the nurse apply when providing care for this client? Select all that apply.
Selected -Changes in sleeping and eating patterns may be signs of stress in a family. -Illness in one family member can affect all family members. -Children respond more positively when they know what is going on. [xxx] -A family member may have more than one role at a time in the family. Correct response: -Illness in one family member can affect all family members. -A family member may have more than one role at a time in the family. -The effects of an illness on a family depend on the stage of the family's life cycle. [left out] -Changes in sleeping and eating patterns may be signs of stress in a family. Explanation: Illness in one family member can affect all family members, even children. Families do not necessarily become stronger when one family member is ill. Illnesses can create stressful family environments, which may put a lot of pressure on family members. When one family member cannot fulfill a role because of illness, the roles of the other family members are affected. While age-appropriate information is provided to the child, children are still impacted by the change in living situation and stress in the environment. And being informed may not always be the best thing for children. [!!!!!!] Families move through certain predictable life cycles (such as birth of a baby, a growing family, adult children leaving home, and grandparenting). [!!!!!!] The impact of illness on the family depends on the stage of the life cycle as family members take on different roles and the family structure changes. Illness produces stress in families; changes in eating and sleeping patterns are signs of stress.
The family of a hospitalized client demonstrates understanding of the teaching about legal documents related to end-of-life care such as "advance directive" and "power of attorney" when they make which statements? Select all that apply.
Selected: -"Advance directives give instructions about future medical care and treatment." -"Medical power-of-attorney or durable power-of-attorney for health care is a document that lists who can make health care decisions should a person be unable to make an informed decision for himself or herself." Correct: -"Advance directives give instructions about future medical care and treatment." -"If people are not capable of communicating their wishes, health care providers and family together can agree on measures or actions that will be taken." -"Medical power-of-attorney or durable power-of-attorney for health care is a document that lists who can make health care decisions should a person be unable to make an informed decision for himself or herself." Explanation: -Advance directives are written statements of person's wishes related to health care if they are unable to decide for themselves. Power of attorney is a written authorization to represent or act on another's behalf in private affairs, business, or some other legal matter. These documents relate to current or future health care and not past medical history. Competent adults are responsible for their own health care decisions and their own right to accept or refuse treatment. Advance directives are used when the person cannot make the decision. Medical power-of-attorney is a term used to describe the person who makes health care decisions should someone be unable to make informed decisions for himself or herself. The focus is not primarily financial access. I didn't pick the 2nd one bc I thought it was saying that the HCP should influence decisions but in this case it's just physician-family collaboration in the plan of care.
The nurse facilitating the medication management group notices that a particular client consistently chooses a position on the perimeter of the group. In order to be culturally mindful about the origin of this behavior, what question would the nurse ask the client?
Selected: "What are your reasons for staying so far away from the people in the group?" Answer: "Where will you be comfortable sitting and still remain a part of the group?" Rationale: In being culturally sensitive to the client's need, the nurse will ask where the client will be comfortable sitting and still able to participant in the group. Asking the client the reasons for a particular behavior, thinking that the client is having problems with the group, and making an assumption about the cultural meaning of being touched by another person are not useful questions. I get it now. I thought the question was asking me to investigate the origin of the behavior but it just asks how to be "mindful" about the origin of this behavior?
A client has been prescribed valproic acid for the treatment of bipolar disorder. The client tells the nurse, "I know that vitamin B can help with depressive episodes, so I am going to give that a try." What is the nurse's best response?
Selected: "Where did you first learn about the possible benefits of vitamin B?" Answer: "Be sure to dialogue with your care provider before you start taking vitamin B supplements." Rationale: The priority action is educate the client about the need to inform the care provider before taking supplements, over-the-counter medications, or herbal remedies. Many contraindications exist, but it is inaccurate to state that all herbal remedies are contraindicated. The source of the client's beliefs and the client's long-term plans are relevant, but the need for consultation with the provider is the priority.
The nurse has observed that a client who identifies as a Mormon has drunk the coffee that was on the breakfast tray. How should the nurse best interpret this observation?
Selected: Alcohol is the only beverage that is prohibited in this religion Answer: The client's personal religious practices may differ from those of the larger religious group. Rationale: When identifying characteristics or behaviors of particular religions it is important to know that there is often wide variation between individuals and groups. Not every person who says that he or she is a Mormon will always forgo coffee, for example, even though it is not acceptable. At the same time, it would presumptuous to conclude that the client no longer adheres to this particular religion. Further info: "Mormons are taught not to drink any kind of alcohol (see D&C 89:5-7). Mormons are also taught not to drink "hot drinks," meaning coffee or any tea other than herbal tea (see D&C 89:9), and not to use tobacco (see D&C 89:8)..." Source: https://pacific.churchofjesuschrist.org/why-mormons-dont-drink-alcohol-tea-and-coffee
The nurse in the preoperative setting is preparing the client for surgery. During completion of the preoperative checklist the client states, "I have a question about my surgery." What is the next action by the nurse?
Selected: Answer the client's question regarding the surgery. Correct: Contact the surgeon to answer the client's question. Explanation: If a client verbalizes questions regarding a surgery, then informed consent cannot be given. To have informed consent, the surgeon performing the procedure must tell the client about the treatment, tests, alternative treatments, and the risks and benefits of each. The surgeon is responsible for ensuring that informed consent is obtained. The nurse would contact the surgeon to answer the client's questions prior to the start of the procedure, not answer the client's questions. Informed consent would be obtained prior to the client being transported to the operating room; therefore, having the circulating nurse convey the information is inappropriate. Although it may be necessary to delay the surgery, it would be most appropriate to contact the surgeon to answer the client's question. Ugh I knew that only the surgeon can educate the pt about the procedure, but I thought "What if the pt just has question about what time the surgery is scheduled for?"
The nurse is caring for a client who recently lost an infant to sudden infant death syndrome (SIDS). The client talks about how going back to work last week and that the couple want to become pregnant again soon to have another baby. The client reports feeling sad sometimes, but also feeling happy sometimes. What stage of grief does this client demonstrate?
Selected: Bargaining Answer: Acceptance Rationale: This client demonstrates acceptance of the new reality. The client shows both dealing with the grief and resuming a more normal life again, such as going back to work and planning another pregnancy. It is normal for the client to still experience times of happiness and sadness, but this shows the client has moved into the acceptance stage and is accepting the loss of the baby without trying to change it. Denial would be characterized by refusing to admit the loss of the baby was real, such as believing that the baby was not really dead. Delusion is not a stage of grief, but rather a false or irrational belief that a person holds strongly to despite proof to the contrary. Bargaining would be characterized by trying to make deals to change the outcome, such as "Take me instead and let my baby live."
The parent of an Indonesian young adult reports through an interpreter to the nursing supervisor that the staff nurse sometimes shouts at the client. The nurse tells the supervisor that she has not been shouting at the client. What would the supervisor expect to note after observing a care interaction between the staff nurse and the young adult adolescent client?
Selected: Loud music is playing in the room. Answer: There is a language barrier present. Rationale: When a language barrier is present, it is a common occurrence for the nurse to raise the voice if the client does not seem to understand what is being said. When loud music is playing, the nurse would simply ask for the volume to be temporarily decreased. There is no evidence to indicate the presence of a nurse-client conflict, nor is the care painful.
A nurse is providing home care to a client with a foot ulcer related to diabetes. The client needs daily insulin injections. Family caregivers do not possess the technical skills to inject insulin. Which should the nurse keep in mind?
Selected: Nurses should avoid asking the family caregivers to conduct the skilled task. Correct: The nurse needs to be creative in integrating the technical and relational aspects of care. Explanation: The nurse needs to be creative in integrating the technical and relational aspects of care. The current reimbursement system does not recognize the family's nontechnical value priorities. Nurses are expected to educate the family caregivers to conduct the skilled task where possible. In this case, the nurse can teach the family caregivers to inject insulin. Family caregivers can be perceived to be nonsupportive of good care if the families do not follow through.
A nurse is caring for an infant who is to be administered an enema. What spiritually oriented interventions could the nurse follow with newborns and infants?
Selected: Provide the infant with soft toys or a feeding bottle. Answer: Encourage parents to be present during the treatment. Explanation: When caring for infants and newborns, the best nursing intervention is to encourage the parents to be present during the medical treatment. There is no need for the nurse to ask for a child specialist to be present during the treatment. Instead, the nurse should involve the parents in the caring process as the infant will feel more secure and comfortable in the presence of the parents. Providing the infant with toys, a feeding bottle, or trying to explain that it will be over soon will not pacify the child. I guess the toy/feeding bottle thinking came from clinical advice that sugar water can calm babies? But the best way to meet spiritual needs would be to have that parent / familiar presence.
A client in home hospice care verbalizes to the caregiver a desire to meet with the client's minister. The caregiver does not want the minister to visit or to interact with the minister because of different values and beliefs and asks the home health nurse how to handle this situation. To prevent further disagreement between the client and caregiver, what is the best recommendation for the nurse to implement?
Selected: Something about mediating the conflict between both parties. Answer: Arrange for an alternative caregiver to be available for the client when the minister visits. Rationale: It is important that the client's spiritual needs are met and that the caregiver's opinions and needs are respected. Therefore, arranging for an alternative caregiver to be there during the visit is a reasonable solution. Teaching the caregiver to be assertive and discussing other spiritual counseling options does not meet the client's need. Since both the client and caregiver have different positions, it would require time to resolve the underlying issues. Also, the client is currently on hospice and it is important to find a reasonable compromise to allow the client's needs to be addressed.
A nurse cares for a client who believes in Hinduism. The nurse understands that Hindus believe illness is caused by which type of behavior?
Selected: past and current life actions Correct: past and current life actions Explanation: According to Hinduism, illness is the result of past and current life actions. The right hand is seen as holy, and eating and intervention need to be done with the right hand to promote clean healing. The spiritual health belief in Hinduism is not that illness is from consumption of dirty food, unhygienic habits, or poor worship of God.
The emergency room nurse is providing care to a client who admits to being a victim of domestic violence. Which statement by the client indicates to the nurse that the client will accept safe shelter living? Select all that apply.
Selection: -"A social worker can help me set up a place to stay." -"I will let my partner know that I am not returning home." [xxx] -"I would like to get a restraining order from my partner." Answer: -"A social worker can help me set up a place to stay." -"I would like to get a restraining order from my partner." Rationale: The two client statements, "A social worker can help me set up a place to stay" and "I would like to get a restraining order from my partner," indicate that the client is ready to change living conditions. If the client tells the partner the client is not coming home or accepts a house from the family then the client is not gaining independence. The statement that the client still needs a plan for the children does not indicate that the client is ready for a change in living conditions and independence.
