Examkin

Soru

Zorluk: OrtaHigh Risk Behaviors

A pregnant client at 12 weeks of gestation is being evaluated at an obstetric clinic. While taking vital signs, the client states to the practical nurse, 'I still have a glass of wine on the weekends because it helps me unwind.' Which of the following actions should the practical nurse take? (Select all that apply.)

  1. Document the client's statement about alcohol consumption as a direct quote in the electronic health record.Cevap
  2. B
    Ask the client, 'Why do you continue to consume alcohol when it could harm the fetus?'
  3. Explain to the client that there is no established safe level of alcohol intake during any stage of pregnancy.Cevap
  4. D
    Develop and initiate an individualized nursing care plan for substance use cessation.
  5. Communicate the client's reported alcohol use to the healthcare provider or supervising registered nurse.Cevap
  6. F
    Share the information about the alcohol consumption with the client's accompanying family members to build a support system.

Cevap

The practical nurse should document the exact quote, explain that no amount of alcohol is safe during pregnancy, and report the finding to the supervising nurse or provider.
When a client discloses a high-risk behavior such as alcohol use during pregnancy, the practical nurse must prioritize safety, objective documentation, and interdisciplinary communication. The correct interventions include providing established, factual education that no level of alcohol is safe, documenting the client's subjective data exactly as stated, and collaborating by reporting the information to the RN or provider for further assessment and intervention.

Adım Adım Çözüm

1
Analyze the client's statement to identify the high-risk behavior.
The client is consuming alcohol during the first trimester of pregnancy.
Recognizing the risk is the first step in determining appropriate nursing interventions.
2
Determine the appropriate health promotion teaching.
Identify that the client needs evidence-based information stating no alcohol is safe during pregnancy.
Providing factual health education aligns with the practical nursing scope of practice for health promotion.
3
Identify required documentation and reporting actions.
The nurse must document the exact quote objectively and report the finding up the chain of command.
Accurate data collection and collaboration are essential to ensure the RN and provider can arrange necessary support services.
4
Eliminate actions that violate therapeutic communication, scope of practice, or privacy laws.
Discard options involving asking 'why', independently writing care plans, or sharing data with family.
These actions represent common clinical and legal errors in nursing practice.

Anahtar Kavram

Identifying and managing high-risk behaviors during pregnancy within the practical nursing scope.
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Konular

High Risk Behaviors

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