A 17-12 months-old male comes to the health center for his pre-university bodily exam. During
the interview, he tells the realistic nurse (PN) that even though he has been actively engaged in
sports activities, song, and lecturers, he nonetheless does no longer recognize what he would
love to do after graduation. How ought to the PN reply?
A. Encourage him to speak along with his dad and mom about his confusion approximately his
future.
B. Recommend that he choose one region on which to recognition so that he starts offevolved to
develop a less assailable sense of identification.
C. Acknowledge the difficulty of this choice-making whilst supporting his choice to continue to
explore his options.
D. Suggest that he explore unique component-time work alternatives whilst going to college. -
ANS-C. Acknowledge the difficulty of this decision-making while supporting his desire to hold to
explore his options.
Erikson's stage of adolescent experience of identification is a development milestone that
frequently keeps into early younger maturity whilst profession alternatives in college are
explored. Acknowledging the teenager's difficulty in deciding about his destiny gives assist that
his search is a regular degree.
A 9-yr-antique boy who had an emergency appendectomy all through the night awakens and
starts offevolved to cry when he does no longer see his mother and father on the bedside. He
has an IV and a dressing protecting the operative web site. What movement ought to the
sensible nurse (PN) put in force?
A. Encourage the child to loosen up due to the fact huge boys do now not cry.
B. Locate his mother and ask her to live on the bedside together with her son.
C. Ask the kid to consider the surgical event and examine his pain degree.
D. Call the healthcare issuer for a prescription for a different analgesic. - ANS-C. Ask the child to
recall the surgical occasion and assess his pain level.
A nine-12 months-vintage can use cognitive capabilities to understand the nurse's explanation
which must assist him recognition and determine his postoperative pain.
,A consumer admitted with major melancholy is positioned on suicide precautions. While
orienting the consumer to the unit, what hobby ought to the sensible nurse (PN) put into effect?
A. Assign the equal unlicensed assistive employees for one on one observations.
B. Explain the reason and implementation of suicide precautions.
C. Discuss that site visitors could be restrained at some point of the customer's near statement
period.
D. Obtain the patron's permission to go looking his non-public items. - ANS-B. Explain the cause
and implementation of suicide precautions.
A purchaser on suicide precautions must be knowledgeable approximately the reason and
parameters of suicidal precautions, which encompass use of decided on private gadgets
beneath direct supervision, elimination of sharp gadgets, observation at common durations, and
restrict to the unit.
A consumer has collapsed whilst getting out of bed, has no pulse, and is not breathing. After
calling for assist and an automatic external defibrillator (AED), which motion have to the
sensible nurse (PN) take?
A. Give brief brief breaths.
B. Palpate for a carotid pulse.
C. Defibrillate the use of the AED.
D. Begin cardiac compressions. - ANS-D. Begin cardiac compressions.
Basic Life Support (BLS) for a purchaser who's subconscious and no longer breathing need to
start with cardiac compressions.
A consumer is admitted with a tumor of the hypothalamus. Which finding ought to the practical
nurse (PN) document to the fee nurse?
A. A pulse charge of ninety eight beats/min.
B. Respirations of 20 breaths/min.
C. An oral temperature of a hundred and one.8° F.
D. A blood stress of one hundred thirty/80 mm Hg. - ANS-C. An oral temperature of one zero
one.8° F.
The hypothalamus controls body temperature, so variant in the temperature must be suggested
to decide if the elevation is associated with contamination or cerebral pathology.
A consumer is admitted with possible head trauma after a motor car collision. Which action need
to the sensible nurse (PN) put in force?
A. Auscultate heart sounds.
B. Monitor purchaser's weight.
,C. Check for verbal and motor reaction.
D. Auscultate lung and stomach sounds. - ANS-C. Check for verbal and motor response.
A customer experiencing a disturbing closed head injury should be monitored for signs of
improved intracranial pressure (ICP). A neurologic examination, which includes the Glasgow
Coma Scale, is carried out the stumble on early signs of ICP, as manifested via adjustments in
verbal and motor response.
A client lately diagnosed with diabetes may be very indignant about the modified instances. How
ought to the realistic nurse (PN) respond?
A. "You appear disillusioned approximately the analysis. Let's talk about your feelings."
B. "Try no longer to be irritated due to the fact you're receiving the satisfactory care possible."
C. "Anger is most effective an emotion, however strive no longer to be angry with healthcare
vendors."
D. "You study speedy and will probable handle the difficult treatments very well." - ANS-A. "You
appear disenchanted approximately the diagnosis. Let's talk about your feelings."
(A) demonstrates acceptance of the customer's mind and feelings and encourages open verbal
exchange.
A patron visits the health facility with complaints of sleep loss and wants a prescription for
sleeping capsules. The sensible nurse (PN) learns that the consumer is likewise drinking tea on
the night meals. What motion must the PN enforce?
A. Talk to the purchaser about history of modifications in napping conduct.
B. Determine if the tea is caffeinated or has an herbal supplement in it.
C. Instruct the purchaser on the right dose for the dozing drugs.
D. Have a translator interpret all instructions approximately the sleeping tablets. - ANS-B.
Determine if the tea is caffeinated or has an herbal supplement in it.
Determining if the tea is caffeinated is the first motion.
A patron who delivered a normal toddler 4 hours in the past has been unable to void. What
nursing intervention need to the realistic nurse (PN) put into effect first?
A. Increase oral fluid intake to 2500 ml.
B. Use urinary catheter to drain bladder.
C. Rinse the perineum with warm water.
D. Palpate suprapubic location for distention. - ANS-C. Rinse the perineum with warm water.
, Non-invasive measures, together with pouring warm water over the customer's perineum to
create the urge to urinate should be put into effect first.
A consumer who had a cardiac catheterization 2 hours ago has a strain dressing inside the left
groin. The sensible nurse (PN) is taking crucial signs q2 hours. Which extra evaluation ought to
the PN make?
A. Pedal pulse.
B. Apical pulse.
C. Femoral pulse.
D. Brachial pulse. - ANS-A. Pedal pulse.
Pedal pulses ought to be monitored q2 hours publish-cardiac catheterization to ensure arterial
perfusion distal to the femoral arterial get right of entry to is undamaged.
A consumer who is three days postoperatively for a coronary artery skip graft surgical procedure
(CABG) has a serum potassium stage of 4.5 mEq/L. What motion have to the sensible nurse
(PN) put into effect based totally in this locating?
A. Notify the healthcare provider.
B. Document the finding simplest.
C. Administer potassium replacement.
D. Decrease the IV answer flow price. - ANS-B. Document the finding most effective.
Post CABG can contribute to hypokalemia from hemodilution, nasogastric suction, or diuretic
remedy, so monitoring serum electrolytes is vital to decide the patron's chance for cardiac
dysrhythmias. The consumer's serum potassium is inside normal limits (norm three.5 to five.0
mEq/L) and requires documentation handiest.
A consumer who is prepared for transport from the postanesthesia care unit (PACU) to the
postoperative unit maintains to complain of ache on the incision web page. What motion must
the realistic nurse (PN) enforce?
A. Administer a dose of analgesic as written in the patron's postoperative prescriptions.
B. Give a half-dose of the prescribed postoperative dosage of analgesic medication.
C. Consult with the anesthesia healthcare company for a prescribed dose of analgesia.
D. Tell the client that ache remedy can not accept till switch to the postoperative unit. - ANS-C.
Consult with the anesthesia healthcare provider for a prescribed dose of analgesia.
A consumer who stays in the postanesthesia care unit may nonetheless have residual
consequences of anesthesia, so the healthcare company ought to be consulted for a dose that
is decreased or distinctive than prescribed.
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