EAQ Patient Centered Care
A nursing instructor asks a student nurse about controlling a nosebleed in a toddler. Which statements made by the student indicate the need for further teaching? Select all that apply. 1. "I should keep the child's head tilted back." 2. "I should keep the child in a sitting position." 3. "I should put ice on the bridge of the child's nose." 4. "I should apply pressure to the anterior of the nose." 5. "I should keep the child's mouth closed for some time."
Correct Answer 1. "I should keep the child's head tilted back." 5. "I should keep the child's mouth closed for some time." While controlling a nosebleed in a toddler, the nurse should keep the head of the child forward, and the nurse make the child breath through his or her mouth for some time. Hence, when the student says that child's head should be kept backward, mouth closed, it indicates the need for further teaching. The nurse should keep the child in a sitting position and apply ice over the bridge of the child's nose. Pressure should be applied over the anterior part of the nose to stop bleeding.
A newly immigrated older Chinese adult is brought to a mental health clinic when family members become concerned that their parent is depressed. In an attempt to conduct a culturally competent assessment interview, the nurse asks certain questions. Which questions does the nurse ask? Select all that apply. 1. "What brought you here for treatment today?" 2. "What do you believe is the cause of your depression?" 3. "Does religion have a role in your perception of health and wellness?" 4. "Do you have insurance that includes coverage of mental health issues?" 5. "Have you ever sought treatment for a mental health problem before?"
Correct Answer 1. "What brought you here for treatment today?" 2. "What do you believe is the cause of your depression?" 3. "Does religion have a role in your perception of health and wellness?" 5. "Have you ever sought treatment for a mental health problem before?" Determining the client's perception of the problem is an essential question that allows cultural factors to be included. Encouraging the client to discuss the problem will facilitate a clearer understanding of the factors involved. Religion often plays a significant role in a client's view of health, wellness, and recovery. Knowing whether a client has ever undergone treatment for a mental health problem reveals mental health history and how previous issues were addressed. Insurance coverage is not a relevant question for the nurse to ask a client.
A client is admitted to a mental health facility for depression. What action should a nurse take to help the client develop a positive self-regard? 1. Set limits on the client's negative behaviors. 2. Involve the client in activities that promote success. 3. Demonstrate approval of the client's efforts at every opportunity. 4. Encourage the client to participate in activities with other clients.
Correct Answer 2. Involve the client in activities that promote success. Self-esteem and feelings of competence are increased when a person experiences success. Although setting limits on the client's negative behaviors is a necessary intervention when a depressed client tries to engage in self-harm, it will not promote feelings of self-esteem. Clients recognize unwarranted praise and often interpret such responses as a form of belittlement or pity. Encouraging the client to participate in activities with other clients may or may not increase self-esteem; also, the client may not have the physical or emotional energy to interact with other clients.
A registered nurse is explaining healthcare settings and services to a nursing student. Which scenario mentioned by the registered nurse is considered secondary acute care? 1. A nurse prepares a client who has suffered from repeated cerebral attacks for a CT scan. 2. A nurse is performing physical examinations and monitoring fetal movement in a pregnant woman. 3. A nurse is teaching family members about the importance of being vaccinated and the risks associated with a lack of vaccinations. 4. A nurse is checking a client's heart rate and blood pressure before administering entacapone and isoproterenol concurrently.
Correct Answer 1. A nurse prepares a client who has suffered from repeated cerebral attacks for a CT scan. Secondary acute care includes emergency care, acute medical-surgical care, and radiological procedures for acute problems. Preparing a client for a CT scan after repeated cerebral attacks qualifies as secondary acute care. Caring for a pregnant woman by performing physical examinations and monitoring fetal movement is considered primary care (health promotion). Teaching family members about the importance of being vaccinated and the risks of missing vaccinations are examples of preventive care. Checking the client's heart rate and blood pressure before administering medication is an example of preventive care.
The hypertonicity of the muscles in an infant with cerebral palsy causes scissoring of the legs. The nurse teaches the mother that the preferred way to carry the infant is in a sitting position in what way? 1. Astride one of her hips 2. Strapped in an infant seat 3. Wrapped tightly in a blanket 4. Under the arm in a football hold
Correct Answer 1. Astride one of her hips Carrying the infant astride the parent's hip prevents scissoring by keeping the infant's legs abducted. An infant seat will not prevent scissoring. Tight wrapping maintains the infant's legs in a scissored position. When the football hold is used, the infant is carried in a supine position with the legs adducted, which promotes scissoring.
What is a common characteristic of Sjögren's syndrome (SS)? 1. Dry eyes 2. Muscle cramping 3. Urinary tract infection 4. Elevated blood pressure
Correct Answer 1. Dry eyes Sjögren's syndrome (SS) is a group of problems that often appear with other autoimmune disorders. Problems include dry eyes, which are caused by autoimmune destruction of the lacrimal glands. Muscle cramping, urinary tract infection, and elevated blood pressure are not common characteristics of Sjögren's syndrome (SS).
A nurse is caring for a client with type 1 diabetes who developed ketoacidosis. Which laboratory value supports the presence of diabetic ketoacidosis? 1. Increased serum lipids 2. Decreased hematocrit level 3. Increased serum calcium levels 4. Decreased blood urea nitrogen level
Correct Answer 1. Increased serum lipids With diabetic ketoacidosis, serum lipid levels are high because of the increased breakdown of fat. Serum lipid levels can go so high that the serum appears opalescent and creamy. With diabetic ketoacidosis the hematocrit level generally is increased because of dehydration. The calcium level is unrelated to diabetic ketoacidosis. With diabetic ketoacidosis the blood urea nitrogen level generally is increased because of dehydration.
The nurse is teaching a client who underwent a hypophysectomy for hyperpituitarism about self-management. Which actions performed by the client could cause complications on the second post-operative day? Select all that apply. 1. Nose blowing 2. Teeth brushing 3. Bending forward 4. Breathing through the mouth 5. Lying in a semi-Fowler's position
Correct Answer 1. Nose blowing 2. Teeth brushing 3. Bending forward After a hypophysectomy a drip pad is placed under the nose of the client for 2 to 3 days. Therefore, the client should not blow their nose, brush their teeth, or bend forward because these activities can increase intracranial pressure and delay healing. Because of the nasal packing, the client is advised to breathe through their mouth. Lying in a semi-Fowler's position will not interfere with the nasal packing; therefore, it will not cause any complication.
The nurse is caring for a client in labor whose medical report states posterior pituitary hormone deficiency. Which medication administration is required for the client considering the medical condition? 1. Oxytocin to promote uterine contractions 2. Prolactin to promote breast milk ejection 3. Luteinizing hormone to promote painless labor 4. Follicle-stimulating hormone to promote estrogen secretion
Correct Answer 1. Oxytocin to promote uterine contractions Oxytocin is a posterior pituitary hormone that acts on the uterus to stimulate uterine contractions. Therefore the nurse should administer oxytocin to the client. Prolactin is an anterior pituitary hormone that promotes breast milk production, not milk ejection. Luteinizing hormone is an anterior pituitary hormone that stimulates progesterone secretion and ovulation and does not promote painless labor. Follicle-stimulating hormone is secreted by the anterior pituitary and is involved in estrogen secretion and follicle maturation.
The registered nurse finds that a client cared for by a student nurse has developed an infection. Which action of the student nurse does the registered nurse suspect to be the cause of infection? 1. Use of a wet dressing 2. Exposure of the dressing to air 3. Use of high-absorbent dressing materials 4. Use of dressing materials with enzyme preparation
Correct Answer 1. Use of a wet dressing Wet dressings may promote the growth of organisms, leading to infection. The wound surface on exposure to air can dehydrate surface cells and form scabs. This may convert the wound to a deeper injury. High-absorbent material used for prolong periods may injure the wound. Dressing materials with enzyme preparation helps promote dead tissue removal; therefore it should not cause infection.
Which skin infection would cause facial paralysis? 1. Candidiasis 2. Herpes zoster 3. Herpes simplex 4. Dermatophytosis
Correct Answer 2. Herpes zoster Facial paralysis is the clinical sign of Bell's palsy, a complication of the herpes zoster infection. This is seen when the trigeminal nerve is infected by the varicella-zoster virus. Candidiasis is a fungal infection not associated with Bell's palsy. Herpes simplex is a viral infection and may not cause Bell's palsy. Dermatophytosis is also a fungal infection not associated with Bell's palsy.
What should the nurse's approach be when when working with clients who use manipulative, socially acting-out behaviors? 1. Strict, punishing, and restrictive 2. Sincere, cautious, and consistent 3. Supportive, accepting, and friendly 4. Sympathetic, nurturing, and encouraging
Correct Answer 2. Sincere, cautious, and consistent A sincere, cautious, and consistent attitude limits this type of individual's ability to manipulate both situations and staff members. A strict, punishing, and restrictive approach may create a power struggle and limit the development of a therapeutic nurse-client relationship. When accepting the person, the nurse should not support negative behavior; a friendly attitude may encourage further problem behavior. A sympathetic, nurturing, and encouraging approach may encourage the clients to continue in this lifestyle rather than learn appropriate ways to relate to others.
The nurse is caring for a client who has an implanted port and is receiving intravenous fluids. To decrease the risk of infection, the nurse should change the noncoring needle how often? 1. Every 3 days 2. Every 5 days 3. Every 7 days 4. Every 9 days
Correct Answer 3. Every 7 days Best practice guidelines indicate that noncoring needles be changed at least every 7 days to decrease risk of infection. Changing a noncoring needle every 3 to 5 days is too frequent and increases the risk for infection as well as client discomfort. Changing a noncoring needle every 9 days increases the risk of infection due to the prolonged length of time the needle is in place.
What is the most important nursing intervention for minority adolescents? 1. Identifying individuals at risk for substance abuse 2. Providing counseling to adolescents during rehabilitation 3. Helping ensure improved access to appropriate healthcare 4. Guiding minority adolescents to prevent injuries and accidental deaths
Correct Answer 3. Helping ensure improved access to appropriate healthcare Minority adolescents experience a greater likelihood of health problems and barriers to healthcare. Hence, helping improve access to appropriate healthcare is the most important intervention for the nurse working with minority adolescents. Identifying individuals who are at risk for substance abuse, providing counseling to adolescents during rehabilitation, and guiding adolescents to help prevent injuries and accidental deaths are applicable to all adolescents.
A client has been in the alcohol detoxification unit for 5 days. In the evening the client complains of numbness and tingling in the feet and legs. What is the most appropriate nursing intervention? 1. Massaging the client's legs with lotion 2. Emphasizing the need to rest and keep the legs elevated 3. Keeping the bed linens off the client's legs with a mechanical aid 4. Monitoring the progression of symptoms and assessing the pedal pulses frequently
Correct Answer 3. Keeping the bed linens off the client's legs with a mechanical aid Peripheral neuropathy is present, and keeping the bedclothes off the client's legs will limit tactile stimulation. The nurse may choose to monitor the progression of symptoms and assess the pedal pulses frequently, but these symptoms are not caused by impaired circulation; rather, they are the result of alcohol-induced peripheral neuropathy. Massaging the client's legs or having the client rest and elevate the legs will do little to relieve the discomfort or ease the neurologic symptoms.
During the first hour after a cesarean birth, a nurse notes that the client's lochia has saturated one perineal pad. In light of the knowledge of expected lochial flow, what should the nurse conclude that this may be an indication of? 1. Scant lochial flow 2. Postpartum hemorrhage 3. Retained placental fragments 4. Lochial flow within expected limits
Correct Answer 4. Lochial flow within expected limits It is expected that as many as two perineal pads will be saturated in the first hour. A scant flow probably would not saturate even one pad. Hemorrhage would saturate more than two pads in 1 hour. Retained placental fragments would be accompanied by heavy bleeding and require more than two pads during the first hour.
The spouse of a client who is dying tells the primary nurse that the client is asking the nurses to leave the pain medication on the bedside table and fears they are being saved for a suicide attempt. The nurse knows that the staff members have mixed feelings about the client's terminal status and prolonged pain. What is the most ethically appropriate intervention by the nurse? 1. Reporting the information about the medication to the nurse manager 2. Reminding the nurses that they should not leave the medication at the bedside 3. Asking the nurse manager to address the medication problem and the staff's feelings 4. Suggesting a nursing conference to discuss the medication problem and the staff's feelings
Correct Answer 4. Suggesting a nursing conference to discuss the medication problem and the staff's feelings Suggesting a nursing conference to discuss the medication problem and the staff's feelings is a positive approach because it attempts to address staff members' feelings as well as the medication problem; the nurse therefore is taking an ethically appropriate action without being moralistic or authoritarian. Reporting the information about the medication to the nurse manager abdicates the primary nurse's responsibility and may prompt anger and guilt among the staff members. Reminding the nurses that they should not leave the medication at the bedside does not address the nurses' feelings. Asking the nurse manager to address the medication problem and the staff's feelings abdicates the primary nurse's responsibility and may create anger and guilt among the staff members.
Which parental statement indicates correct understanding of toddler actions that correspond with the preoperational stage of development? Select all that apply. 1. "My child is expected to use past tense verbs." 2. "My child should begin to imitate animal sounds." 3. "My child should begin to gesture up and down." 4. "My child should begin to use two- to three-word phrases." 5. "My child is expected to find hidden objects in only one location."
Correct Answers 1. "My child is expected to use past tense verbs." 4. "My child should begin to use two- to three-word phrases." During the preoperational stage of development the toddler-age client is expected to use past tense verbs and two- to three-word phrases. These parental statements indicate correct understanding. Imitating animal sounds, gesturing up and down, and finding hidden objects in only one location is an expectation during the sensorimotor stage of development.
