Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
What should the nurse include in pre-discharge education for this child's parents? Select all that apply.
A. Contact information for community resources
Correct- The nurse should provide the parents with the phone numbers and websites of local organizations that offer support and counseling for families who have experienced a traumatic event. The nurse should also encourage the parents to seek professional help if they feel overwhelmed, depressed, or anxious.
B. Information about pool safety
Correct- Educating the parents about pool safety is crucial to prevent future accidents. This information can include guidelines for supervision, barriers, and measures to prevent drowning incidents.
C. A warning about potential charges for child neglect
Incorrect- While it's important for parents to be aware of the seriousness of child neglect, including this information in pre-discharge education might not be the most appropriate time, especially if the child is showing only minor signs of impact from the incident. This could increase their guilt and distress and damage the therapeutic relationship. The nurse should focus on providing support and education, not judgment or punishment.
D. When to follow up with the child's pediatrician
Correct- The nurse should advise the parents to schedule a follow-up visit with the child's pediatrician within a week of discharge. The nurse should explain that the pediatrician will monitor the child's recovery and check for any signs of complications, such as brain damage, infection, or lung injury.
F. Assessment of the parent's coping skills
Correct- Assessing the parent's coping skills can help identify if they are dealing with any emotional stress or trauma related to the incident. Providing appropriate support or referrals if needed can be beneficial.
This question is an excerpt from Nurse Dive's nursing test bank - RN Hesi Exit Proctored Exam. Take the full exam now
Full Explanation
A. Correct- The nurse should provide the parents with the phone numbers and websites of local organizations that offer support and counseling for families who have experienced a traumatic event. The nurse should also encourage the parents to seek professional help if they feel overwhelmed, depressed, or anxious.
B. Correct- Educating the parents about pool safety is crucial to prevent future accidents. This information can include guidelines for supervision, barriers, and measures to prevent drowning incidents.
C. Incorrect- While it's important for parents to be aware of the seriousness of child neglect, including this information in pre-discharge education might not be the most appropriate time, especially if the child is showing only minor signs of impact from the incident. This could increase their guilt and distress and damage the therapeutic relationship. The nurse should focus on providing support and education, not judgment or punishment.
D. Correct- The nurse should advise the parents to schedule a follow-up visit with the child's pediatrician within a week of discharge. The nurse should explain that the pediatrician will monitor the child's recovery and check for any signs of complications, such as brain damage, infection, or lung injury.
F. Correct- Assessing the parent's coping skills can help identify if they are dealing with any emotional stress or trauma related to the incident. Providing appropriate support or referrals if needed can be beneficial.
Similar Questions
The nurse discovers that an older client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history?
A. Genetically inherited disorders of family members.
Incorrect- Genetically inherited disorders of family members: While a family history of certain disorders might provide some insight, it is not typically the primary cause of elevated serum magnesium levels in an older adult.
B. Frequency of laxative use for chronic constipation.
Correct- Elevated serum magnesium levels are commonly associated with chronic laxative use, especially those containing magnesium-based compounds. Laxatives can lead to excessive magnesium intake, causing hypermagnesemia.
C. Length and frequency of the client's tobacco use.
Incorrect- Smoking is not a common cause of elevated serum magnesium levels.
D. Ingestion of shellfish or fish oil capsules daily.
Incorrect- While dietary sources can contribute to magnesium intake, chronic laxative use is a more likely cause in this context.
Full Explanation
A) Incorrect- Genetically inherited disorders of family members: While a family history of certain disorders might provide some insight, it is not typically the primary cause of elevated serum magnesium levels in an older adult.
B) Correct- Elevated serum magnesium levels are commonly associated with chronic laxative use, especially those containing magnesium-based compounds. Laxatives can lead to excessive magnesium intake, causing hypermagnesemia.
C. Incorrect- Smoking is not a common cause of elevated serum magnesium levels.
D. Incorrect- While dietary sources can contribute to magnesium intake, chronic laxative use is a more likely cause in this context.
In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?
A. Palpate all peripheral pulse points for volume and strength.
Palpating all peripheral pulse points for volume and strength is important for assessing circulation, but it does not directly evaluate the effectiveness of intermittent pneumatic compression (IPC) devices. IPC devices are primarily used to prevent deep vein thrombosis (DVT) and improve venous return, so monitoring for signs of DVT is more relevant.
B. Monitor the amount of drainage from the client's incision.
Monitoring the amount of drainage from the client’s incision is crucial for assessing wound healing and detecting potential infections, but it is not related to the effectiveness of IPC devices.
C. Observe both lower extremities for redness and swelling.
Observing both lower extremities for redness and swelling is the most important assessment for evaluating the effectiveness of IPC devices. Redness and swelling can be signs of DVT, which IPC devices are designed to prevent. Therefore, this assessment directly measures whether the devices are functioning as intended.
D. Evaluate the client's ability to use an incentive spirometer.
Evaluating the client’s ability to use an incentive spirometer is important for preventing postoperative pulmonary complications, but it does not assess the effectiveness of IPC devices.
Full Explanation
The correct answer is choice C. Observe both lower extremities for redness and swelling.
Choice A rationale:
Palpating all peripheral pulse points for volume and strength is important for assessing circulation, but it does not directly evaluate the effectiveness of intermittent pneumatic compression (IPC) devices. IPC devices are primarily used to prevent deep vein thrombosis (DVT) and improve venous return, so monitoring for signs of DVT is more relevant.
Choice B rationale:
Monitoring the amount of drainage from the client’s incision is crucial for assessing wound healing and detecting potential infections, but it is not related to the effectiveness of IPC devices.
Choice C rationale:
Observing both lower extremities for redness and swelling is the most important assessment for evaluating the effectiveness of IPC devices. Redness and swelling can be signs of DVT, which IPC devices are designed to prevent. Therefore, this assessment directly measures whether the devices are functioning as intended.
Choice D rationale:
Evaluating the client’s ability to use an incentive spirometer is important for preventing postoperative pulmonary complications, but it does not assess the effectiveness of IPC devices.
The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behavior(s) indicate the client understands how to maintain balance safely? (Select all that apply.)
A. Bends from the waist to pick trash off the floor.
Incorrect- This behavior is not safe for maintaining balance. Bending from the waist can increase the risk of falling. Clients should bend at the knees and use proper body mechanics to pick up objects from the floor.
B. Widens stance while working near the sink.
Correct- Widening the stance provides a broader base of support, which can help improve balance and stability while working near the sink. This is a safe behavior to maintain balance.
C. Locks knees while preparing food on the counter.
Incorrect- Locking the knees while standing can lead to instability and decreased balance. It is recommended to keep the knees slightly flexed to maintain better balance.
D. Brings a heavy can close to body before lifting.
Correct- Bringing a heavy object close to the body before lifting minimizes strain on the back and helps maintain balance. This is a safe behavior when lifting objects.
E. Leans forward to pull a pan from a high shelf
Incorrect- Leaning forward to pull an object from a high shelf can disrupt the center of balance and increase the risk of falling. It's important to use a step stool or ask for assistance when reaching for items on high shelves.
Full Explanation
A) Incorrect- This behavior is not safe for maintaining balance. Bending from the waist can increase the risk of falling. Clients should bend at the knees and use proper body mechanics to pick up objects from the floor.
B) Correct- Widening the stance provides a broader base of support, which can help improve balance and stability while working near the sink. This is a safe behavior to maintain balance.
C) Incorrect- Locking the knees while standing can lead to instability and decreased balance. It is recommended to keep the knees slightly flexed to maintain better balance.
D) Correct- Bringing a heavy object close to the body before lifting minimizes strain on the back and helps maintain balance. This is a safe behavior when lifting objects.
E) Incorrect- Leaning forward to pull an object from a high shelf can disrupt the center of balance and increase the risk of falling. It's important to use a step stool or ask for assistance when reaching for items on high shelves.