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Soru 1701Soru →

A client recovering from an appendectomy identifies as a member of the Church of Jesus Christ of Latter-day Saints (Mormon). The assigned practical nurse brings the client's breakfast, which includes scrambled eggs, fruit, and a cup of hot coffee. Which action should the nurse take to demonstrate culturally congruent care?

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Cevap: Take the coffee off the meal tray and ask the client if they would prefer a different beverage such as juice or milk.

Cevap

Take the coffee off the meal tray and ask the client if they would prefer a different beverage such as juice or milk.
Members of the Church of Jesus Christ of Latter-day Saints typically observe a health code called the Word of Wisdom, which strictly prohibits the consumption of alcohol, tobacco, and hot drinks—specifically coffee and tea. Culturally competent nursing care requires the practical nurse to advocate for the client by actively removing the prohibited item from the tray before the client has to ask. Offering a culturally acceptable alternative, such as water, milk, or fruit juice, ensures the client's nutritional and hydration needs are met while fully respecting their religious beliefs.

Adım Adım Çözüm

1
Identify the client's cultural and religious dietary restrictions.
The client is a member of the Church of Jesus Christ of Latter-day Saints (Mormon), a faith that prohibits the consumption of coffee, tea, and alcohol.
Understanding specific cultural and religious practices is essential for providing holistic, client-centered care.
2
Assess the provided meal tray against the client's dietary restrictions.
The breakfast tray contains hot coffee, which violates the client's religious dietary laws.
Nurses must actively verify that the diet provided by the facility aligns with the client's prescribed and culturally required dietary needs.
3
Determine the most culturally appropriate nursing intervention.
The nurse should remove the prohibited item before serving the tray and offer an acceptable substitute.
This action demonstrates respect, advocacy, and cultural competence by anticipating and accommodating the client's needs.

Anahtar Kavram

Culturally Congruent Dietary Accommodations
Soru 1702Soru →

A practical nurse is communicating with various clients on a medical-surgical unit. Match each therapeutic communication technique to the nurse's corresponding statement.

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Öğeler

Restating
Offering self
Making observations
Exploring

Eşleşmeler

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Cevap

Restating matches with repeating the client's feeling that their life is over. Offering self matches with sitting with the client for 15 minutes. Making observations matches with noticing the client wringing their hands. Exploring matches with asking the client to tell more about their anxiety.
Each technique represents a distinct therapeutic approach: Restating echoes the client's words; Offering self provides unconditional presence; Making observations notes behaviors to prompt discussion; and Exploring gently invites the client to elaborate on specific thoughts.

Adım Adım Çözüm

1
Analyze 'Making observations'
Matches with 'I notice you are wringing your hands and pacing the hallway.'
The nurse is verbalizing a direct behavioral observation to invite the client to share their feelings.
2
Analyze 'Restating'
Matches with the nurse repeating 'You feel like your life is over.'
The nurse acts as a sounding board by repeating the client's exact main idea back to them.
3
Analyze 'Offering self'
Matches with 'I have 15 minutes right now, and I would like to just sit here with you.'
The nurse is volunteering their time and presence without demanding any specific action or conversation from the client.
4
Analyze 'Exploring'
Matches with 'Tell me more about the anxiety you experience when taking your new medication.'
The nurse is using an open-ended prompt to gather deeper insight into a specific topic the client mentioned.

Anahtar Kavram

Therapeutic Communication Techniques
Soru 1703Soru →

A practical nurse is caring for a client who is scheduled for a bilateral mastectomy in the morning. The client is pacing the room, wringing their hands, and suddenly states, "I look in the mirror and I just don't know who I will be tomorrow. Maybe I should just cancel the whole thing." What is the most therapeutic response for the practical nurse to make?

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Cevap: It sounds like you are feeling overwhelmed about how this surgery will change you. Tell me more about what you are feeling.

Cevap

The correct answer is the response that reflects the client's feelings about the upcoming surgery and uses an open-ended prompt to encourage further discussion.
The correct response utilizes the therapeutic techniques of reflection ('It sounds like you are feeling overwhelmed...') and open-ended questioning ('Tell me more...'). This approach validates the client's specific fears regarding body image changes and encourages them to verbalize their anxiety, which is essential for processing their emotions before a major surgery.

Adım Adım Çözüm

1
Analyze the client's behavior and statement.
The client is pacing, wringing hands (signs of anxiety), and expressing fear of altered body image and doubt about the surgery.
To identify the underlying emotional need that requires a therapeutic response.
2
Evaluate the communication techniques used in each option.
Identify which options use non-therapeutic blocks (false reassurance, giving advice, asking 'why') versus therapeutic techniques (reflection, open-ended questioning).
To differentiate between therapeutic and non-therapeutic communication.
3
Select the response that best addresses the client's emotional state.
The response that reflects the feeling of being overwhelmed and asks the client to tell more is the most appropriate.
Therapeutic communication aims to validate feelings and encourage the client to express their concerns without judgment.

Anahtar Kavram

Therapeutic Communication: Responding to Anxiety and Body Image Alteration
Tahmini Süre:1m 15s
Soru 1704Soru →

A practical nurse in a family clinic observes several pediatric clients demonstrating behaviors typical of Erikson's psychosocial stages of development. Place these observed behaviors in chronological order from the earliest developmental stage to the latest.

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Cevap

The correct chronological sequence of observed behaviors is: 1) crying for a bottle (infancy), 2) insisting on putting on a jacket (toddlerhood), 3) playing pretend clinic (preschool), 4) showing a completed drawing (school-age), and 5) expressing concern about peer perception (adolescence).
The correct chronological sequence aligns directly with Erikson's theory of psychosocial development: Trust vs. Mistrust (infancy) is followed by Autonomy vs. Shame and Doubt (toddlerhood), then Initiative vs. Guilt (preschool), Industry vs. Inferiority (school-age), and finally Identity vs. Role Confusion (adolescence).

Adım Adım Çözüm

1
Identify the developmental stage for the client crying for a bottle.
Infancy (Trust vs. Mistrust)
The client is entirely dependent on caregivers to meet basic needs like feeding.
2
Identify the developmental stage for the client insisting on putting on a jacket.
Toddlerhood (Autonomy vs. Shame and Doubt)
The client is demonstrating a desire for independence and control over physical tasks.
3
Identify the developmental stage for the client playing pretend clinic.
Preschool (Initiative vs. Guilt)
The client is showing initiative through imaginative play and social interaction.
4
Identify the developmental stage for the client showing a drawing.
School-age (Industry vs. Inferiority)
The client is exhibiting pride in a productive task and seeking recognition for their effort.
5
Identify the developmental stage for the client concerned about peer perception.
Adolescence (Identity vs. Role Confusion)
The client is highly focused on peer acceptance and social identity.
6
Arrange the identified stages in chronological order from youngest to oldest.
Infancy, Toddlerhood, Preschool, School-age, Adolescence.
This sequence accurately reflects human developmental progression according to Erikson.

Anahtar Kavram

Erikson's Psychosocial Stages of Development
Soru 1705Soru →

The Practical Nurse (PN) is assisting the Registered Nurse (RN) and a nurse-midwife during the vaginal delivery of a client at 41 weeks of gestation. After the fetal head is delivered, it immediately retracts tightly against the maternal perineum. Place the following nursing actions in the correct sequential order of priority.

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Cevap

The correct sequence is to first call for help, then flatten the bed, assist with the McRoberts maneuver, apply suprapubic pressure, and finally document the event.
When a fetal head retracts against the perineum (the 'turtle sign'), it strongly indicates shoulder dystocia. The nurse must first call for immediate assistance as this is an emergency beyond the scope of a single practitioner. Next, the bed is flattened to prepare for the McRoberts maneuver (hyperflexing the maternal legs), which is the first-line physical intervention. If that fails, suprapubic pressure is applied to manually dislodge the shoulder. Documentation is completed concurrently or immediately following the maneuvers to ensure an accurate timeline of the prolonged delivery.

Adım Adım Çözüm

1
Call for immediate additional assistance.
Additional healthcare personnel arrive to assist with the obstetric emergency.
The 'turtle sign' indicates shoulder dystocia, a severe emergency requiring multiple staff members for maternal maneuvers and potential immediate newborn resuscitation.
2
Lower the head of the bed to a flat position.
The client is positioned supine and flat on the delivery bed.
A flat position is biomechanically required to properly perform the subsequent McRoberts maneuver.
3
Assist with flexing the client's thighs sharply against her abdomen.
The maternal pelvis tilts, widening the pelvic outlet.
This is the McRoberts maneuver, the primary non-invasive technique to resolve shoulder dystocia.
4
Apply firm, downward pressure above the symphysis pubis.
The anterior fetal shoulder is manually pushed downward.
Suprapubic pressure helps collapse the fetal shoulder, allowing it to pass under the maternal pubic symphysis.
5
Document the timing and maneuvers.
An accurate medical and legal record is created in the client's chart.
Precise documentation of the head emergence time and the exact sequence of maneuvers is required for postpartum and neonatal care planning.

Anahtar Kavram

Management of shoulder dystocia
Soru 1706Soru →

During a routine morning assessment at an assisted living facility, a client refuses breakfast and stares blankly out the window. The client's close friend and neighbor in the facility passed away two days ago. The client tearfully states, "It is simply not fair. I am a burden to everyone, and it should have been me who died." Which response by the licensed practical nurse is the most therapeutic?

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Cevap: It sounds like you are feeling overwhelmed by the unfairness of this loss and are experiencing a heavy sense of guilt.

Cevap

The most therapeutic response is to reflect the client's feelings by stating that they sound overwhelmed by the unfairness of the loss and are experiencing a heavy sense of guilt.
The correct response utilizes active listening and reflection. By summarizing and feeding back the core emotions of unfairness and guilt, the nurse validates the client's feelings and encourages them to continue sharing. It addresses the emotional distress directly without judgment or premature attempts to 'cheer up' the client.

Adım Adım Çözüm

1
Analyze the client's statement and emotional state.
The client is expressing deep emotional pain, a sense of injustice ('not fair'), low self-worth ('burden'), and survivor's guilt ('should have been me').
Understanding the core emotional message is necessary to select a response that addresses the client's immediate psychological needs.
2
Evaluate the response options against principles of therapeutic communication.
Identify communication blocks such as asking 'why' questions, offering unsolicited advice, intellectualizing emotions, or changing the subject.
Eliminating non-therapeutic responses leaves only the option that facilitates open communication and emotional validation.
3
Select the response that demonstrates empathy and reflection.
The correct response restates the client's expressed feelings, validating their pain without attempting to fix it or deflect from it.
Reflection is a powerful therapeutic tool in acute grief, helping the client feel heard and understood.

Anahtar Kavram

Therapeutic Communication in Acute Grief
Soru 1707Soru →

While monitoring the dayroom at a behavioral health center, the practical nurse observes a client with acute mania suddenly stand up, knock over a chair, and begin shouting angrily at another individual. Arrange the following nursing actions in the correct order of priority, from first to last.

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Cevap

The correct sequence prioritizes immediate milieu safety, followed by least-restrictive verbal de-escalation, offering safe alternatives, escalating to the RN, and finally documentation.
In psychiatric nursing, safety of the milieu is the paramount priority. The practical nurse must first clear the area of potential victims. Once others are safe, the nurse follows the principle of least restrictive intervention. This begins with maintaining physical distance and attempting verbal de-escalation. If the client remains agitated, offering choices such as a quiet room or PRN medication provides a slightly more restrictive, yet still voluntary, option. If these independent and collaborative PN actions fail to calm the client, notifying the charge nurse is required to mobilize a response team. Finally, objective documentation is completed after the crisis is managed.

Adım Adım Çözüm

1
Direct other clients to a safe area.
Bystanders are removed from potential harm.
Milieu safety is the highest priority in a psychiatric emergency involving potential violence.
2
Speak to the agitated client calmly from a safe distance.
Initial verbal de-escalation is attempted.
Verbal intervention is the least restrictive method to manage agitation once the area is clear.
3
Offer choices such as a quiet room or PRN medication.
The client is given options to regain control.
Offering choices promotes autonomy and utilizes least restrictive pharmacological or environmental alternatives.
4
Notify the charge nurse.
The care team is alerted.
If basic PN interventions fail, RN or provider assistance is required for potential physical holds or emergent chemical restraints.
5
Document the event.
The incident is officially recorded.
Charting must reflect the objective data and interventions after safety is fully established.

Anahtar Kavram

Crisis De-escalation Priority and Least Restrictive Interventions
Soru 1708Soru →

A practical nurse is reinforcing home care instructions for a client who will perform a fecal occult blood test (FOBT) for colorectal cancer screening. In which order should the nurse instruct the client to complete these steps? Arrange the instructions in the correct sequence.

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Cevap

The correct sequence is to first maintain dietary restrictions, then collect an uncontaminated specimen, apply the first smear to the window, apply a second smear from a different area using a new applicator, and finally seal and transport the card.
Correct adherence to the sequential steps of an FOBT ensures the integrity and accuracy of the colorectal cancer screening. Preparation (dietary restrictions) must occur first. Next, an uncontaminated collection ensures chemical accuracy. Taking two separate samples maximizes the detection of occult blood. Finally, prompt and protected transport guarantees the specimen remains viable for laboratory analysis.

Adım Adım Çözüm

1
Maintain dietary and medication restrictions for 3 days.
The client's system is cleared of substances like red meat, vitamin C, and NSAIDs.
Certain foods and medications can alter the chemical reaction of the guaiac test, causing false-positive or false-negative results.
2
Collect the stool in a clean, dry container.
The stool specimen is isolated from toilet water and urine.
Urine and toilet water can contaminate the sample and interfere with the chemical reagents on the testing card.
3
Apply a smear from one section of the stool to the first window.
The first required sample is secured on the testing medium.
A thin smear allows the reagent developer to properly interact with the stool to detect occult blood.
4
Apply a second smear from a different section to the second window.
Two distinct areas of the stool are sampled.
Bleeding in the gastrointestinal tract can be intermittent or unevenly distributed in the stool; sampling different areas increases detection accuracy.
5
Close the flap and return the card.
The specimen is sealed and delivered to the laboratory.
Protecting the card from light and heat preserves the integrity of the sample for accurate processing.

Anahtar Kavram

Fecal Occult Blood Test (FOBT) Collection and Colorectal Cancer Screening
Soru 1709Soru →

A client with a history of schizophrenia is receiving care on a general medical unit for a systemic infection. While the licensed practical nurse is reinforcing teaching about oral antibiotics, the client suddenly covers both ears, becomes visibly distressed, and states, "The voices are telling me to pull this intravenous line out." Which action should the nurse take next?

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Cevap: Ask the client directly if the voices are commanding them to perform any other harmful actions.

Cevap

Ask the client directly if the voices are commanding them to perform any other harmful actions.
When a client experiences auditory hallucinations that dictate specific actions (command hallucinations), the immediate priority is client and staff safety. The nurse must directly ask what the voices are saying to collect accurate data about the risk of self-harm, violence, or medical non-adherence. This focused, immediate data collection falls firmly within the practical nurse's scope and allows the healthcare team to quickly implement necessary safety precautions.

Adım Adım Çözüm

1
Analyze the client's statement and behavior to identify the clinical presentation.
The client is experiencing an auditory command hallucination directing them to remove medical equipment.
Recognizing command hallucinations is critical because they pose an immediate safety risk.
2
Prioritize nursing actions based on safety, the nursing process (data collection first), and scope of practice.
Immediate data collection regarding the specific instructions given by the voices is required to gauge the level of danger.
The nurse must understand the full extent of the command hallucination to implement appropriate safety precautions before intervening.
3
Evaluate the remaining options against therapeutic communication guidelines and legal scope of practice.
False reassurance, immediate restraints, and intravenous push medications are eliminated.
These actions either block therapeutic communication, violate the principle of least restrictive environment, or exceed the legal limits of practical nursing practice.

Anahtar Kavram

Command Hallucinations and Practical Nurse Scope of Practice
Soru 1710Soru →

An external chemical plant explosion triggers an immediate shelter-in-place order at a skilled nursing facility. While staff members are preparing to secure the building, a client with a tracheostomy suddenly develops severe respiratory distress and cyanosis. An unlicensed assistive personnel (UAP) states they will listen to the client's lung sounds so the practical nurse can rapidly seal the room's air vents with plastic sheeting. Based on emergency response priorities and scope of practice, which action must the practical nurse take?

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Cevap: Direct the UAP to seal the room's air vents while the nurse immediately assesses the client's airway and provides necessary intervention.

Cevap

The practical nurse must direct the UAP to seal the air vents while the nurse immediately assesses the client's airway and provides necessary intervention.
In any emergency situation, the practical nurse must prioritize care based on the Airway, Breathing, and Circulation (ABCs) framework while adhering to the legal scope of practice. Assessment of lung sounds requires clinical judgment and cannot be delegated to an unlicensed assistive personnel (UAP). Therefore, the nurse must personally assess and intervene for the client's compromised airway while safely delegating the non-clinical, task-oriented action of sealing the vents to the UAP. This ensures both immediate client safety and adherence to the shelter-in-place protocol.

Adım Adım Çözüm

1
Analyze the competing priorities in the emergency scenario.
The nurse faces an environmental hazard (chemical explosion requiring shelter-in-place) and an immediate physiological crisis (client with compromised airway).
Identifying all active threats is necessary to apply prioritization frameworks correctly.
2
Apply the Airway, Breathing, and Circulation (ABCs) prioritization framework.
The client's severe respiratory distress and cyanosis take absolute precedence and require immediate, life-saving intervention.
Physiological needs that immediately threaten life always supersede secondary environmental securing tasks when sufficient staff are present.
3
Evaluate the UAP's proposed action against legal scope of practice guidelines.
The nurse must refuse the UAP's offer to listen to lung sounds, as clinical assessment cannot be delegated to unlicensed personnel.
Maintaining client safety and adhering to the Nurse Practice Act remains mandatory, even during internal or external disasters.
4
Formulate a plan that addresses both the client's physiological needs and the environmental hazard.
The nurse delegates the appropriate, non-clinical task (sealing vents) to the UAP while assuming direct responsibility for the complex clinical task (airway management).
Effective delegation maximizes the team's efficiency during an emergency without compromising patient safety or professional boundaries.

Anahtar Kavram

During disaster response and shelter-in-place protocols, the practical nurse must balance environmental hazard containment with immediate life-saving interventions (ABCs) while strictly maintaining legal boundaries regarding delegation to unlicensed personnel.
Tahmini Süre:1m 30s
Soru 1711Soru →

A practical nurse (PN) is providing morning care to a bedbound client when the client's television set sparks and catches fire. Arrange the following actions in the priority order the PN should perform them according to standard fire safety protocols.

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Cevap

The correct sequence of actions follows the RACE acronym: Rescue the client, Alarm the facility, Confine the fire, and Extinguish the fire.
The RACE protocol dictates the correct sequence for fire response in a healthcare facility: Rescue (move the client), Alarm (pull the alarm), Confine (close the door), and Extinguish (use the extinguisher).

Adım Adım Çözüm

1
Identify the immediate threat and prioritize client safety.
The client is moved out of the room.
Rescue is always the first step in fire response to prevent injury or death.
2
Alert others to the emergency.
The fire alarm is activated.
The facility and fire department need to be notified to trigger emergency response systems.
3
Contain the hazard.
The client's door is closed.
Closing the door prevents the spread of fire and smoke to other areas of the unit.
4
Address the fire if possible.
A fire extinguisher is used.
Extinguishing is the last step of initial response, provided the fire is small and it is safe to do so.

Anahtar Kavram

Standard fire safety protocols (RACE acronym) in a healthcare setting.
Soru 1712Soru →

A local healthcare facility's disaster response plan is activated following a mass casualty incident (MCI). The nursing supervisor directs a practical nurse to independently perform initial triage for a large influx of ambulatory survivors arriving at the main entrance. Which action is most appropriate for the practical nurse to take?

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Cevap: Inform the supervisor that initial disaster triage falls outside the practical nurse scope of practice and request a different assignment.

Cevap

The practical nurse must decline the triage assignment because performing initial triage requires advanced assessment skills and clinical judgment that exceed the practical nurse scope of practice.
In any setting, including mass casualty incidents, initial triage and comprehensive assessment require advanced clinical judgment that falls exclusively within the registered nurse (RN) or provider scope of practice. The practical nurse must ensure client safety and professional compliance by declining tasks that exceed their legal scope and requesting an appropriate alternative assignment, such as providing basic first aid or monitoring clients who have already been triaged.

Adım Adım Çözüm

1
Identify the core task being assigned to the practical nurse by the supervisor.
The supervisor is delegating independent initial disaster triage of MCI survivors.
Understanding the precise nature of the assignment is the first step in determining if it falls within the legal scope of practice.
2
Evaluate the assigned task against the legal practical nurse scope of practice.
Initial triage requires comprehensive assessment and advanced clinical judgment, which are outside the practical nurse scope.
The practical nurse scope of practice allows for data collection and focused assessments on stable clients, not unstructured triage of potentially unstable trauma victims.
3
Determine the appropriate, safe response to the nursing supervisor.
The practical nurse must advocate for client safety by refusing the unsafe assignment and requesting a task appropriate for their licensure.
Nurses are legally obligated to refuse delegated tasks that exceed their educational preparation and scope, even during an emergency.

Anahtar Kavram

Practical Nurse Scope of Practice in Disaster Triage
Soru 1713Soru →

An older adult client in a rehabilitation facility tells the practical nurse, "My daughter hasn't visited in three weeks. She must be too busy with her new job to care about an old man like me." Which response by the practical nurse is most therapeutic?

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Cevap: You are upset that your daughter has not been here to visit.

Cevap

The most therapeutic response is to reflect the client's statement by acknowledging they are upset about their daughter not visiting.
The correct response utilizes reflection (or restating). By verbalizing what the client has implied, the nurse validates the client's feelings and encourages them to continue sharing their concerns. This technique demonstrates active listening and empathy.

Adım Adım Çözüm

1
Analyze the client's statement to identify the core emotion being expressed.
The client is expressing feelings of loneliness, sadness, and perceived neglect regarding their daughter's absence.
Understanding the underlying emotion is necessary to formulate an empathetic and supportive response.
2
Evaluate each potential nurse response against established therapeutic and non-therapeutic communication techniques.
Reflecting the client's feelings creates a safe space for them to talk, whereas giving advice, asking 'why', or offering false reassurance acts as a communication block.
Therapeutic communication focuses on the client's needs and encourages them to verbalize their thoughts and feelings without judgment.

Anahtar Kavram

Therapeutic Communication Techniques
Soru 1714Soru →

A practical nurse is providing care in an outpatient family clinic that serves clients across the lifespan. When implementing health promotion and disease prevention strategies, which action by the nurse is correct?

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Cevap: Reinforcing the provider's recommendation for a 45-year-old client with a body mass index (BMI) of 32 to engage in 150 minutes of moderate aerobic exercise weekly.

Cevap

Reinforcing the provider's recommendation for a 45-year-old client with a body mass index (BMI) of 32 to engage in 150 minutes of moderate aerobic exercise weekly.
Reinforcing healthy lifestyle modifications, such as regular moderate-intensity aerobic exercise, is a vital primary prevention strategy for a client with an elevated BMI. This action falls safely within the scope of practice for a practical nurse and promotes cardiovascular health while preventing chronic disease.

Adım Adım Çözüm

1
Analyze the practical nurse's role in health promotion and disease prevention across different developmental stages.
The nurse must reinforce safe primary and secondary prevention strategies while recognizing lifespan-specific norms and contraindications.
Effective health promotion requires accurate knowledge of normal development, aging, and medication safety.
2
Evaluate the action involving the pregnant client.
Administering the MMR vaccine to a pregnant client is incorrect and dangerous.
Live vaccines like MMR carry a risk of transmitting the virus to the fetus and are strictly contraindicated during pregnancy.
3
Evaluate the action involving the 7-month-old infant.
Documenting a developmental delay for a 7-month-old unable to walk is incorrect.
Infants typically begin walking independently between 12 and 15 months of age; expecting this at 7 months demonstrates a lack of knowledge regarding normal pediatric milestones.
4
Evaluate the action involving the older adult client.
Attributing acute confusion over a 12-hour period to normal aging is incorrect and unsafe.
Acute, rapid-onset confusion is a classic sign of delirium often caused by underlying infection, hypoxia, or medication toxicity. It requires immediate medical evaluation, unlike the gradual cognitive decline seen in dementia.
5
Evaluate the action involving the adult client with an elevated BMI.
Reinforcing the recommendation for 150 minutes of weekly aerobic exercise is the correct, health-promoting action.
This action supports weight management and cardiovascular health, representing a safe and highly effective primary prevention strategy that aligns perfectly with the practical nurse's role in patient education.

Anahtar Kavram

Health promotion requires tailoring prevention strategies to the client's lifespan stage while recognizing critical safety contraindications, normal developmental milestones, and acute pathological changes.
Soru 1715Soru →

A practical nurse is providing care for a 3-year-old toddler on a pediatric unit who sustained a spiral fracture of the right femur. The toddler's parent explains, "My child just tripped over a small toy on the carpet and fell down." Recognizing that this mechanism of injury is inconsistent with a spiral fracture, which action should the nurse take?

Cevabı ve açıklamayı göster

Cevap: Notify the charge nurse and initiate the facility protocol for reporting suspected child abuse.

Cevap

Notify the charge nurse and initiate the facility protocol for reporting suspected child abuse.
Spiral fractures in non-ambulatory or newly ambulatory children are highly suspicious for non-accidental trauma, as they require a forceful twisting motion. When a caregiver's explanation does not match the physical evidence, the nurse has a legal obligation as a mandated reporter to notify the appropriate authorities and nursing leadership immediately. Absolute proof is not required to file a report.

Adım Adım Çözüm

1
Evaluate the mechanism of injury against the physical findings.
The nurse identifies that a spiral fracture (a twisting injury) does not typically occur from simply tripping over a toy on a carpet.
Recognizing inconsistencies between a caregiver's story and the actual physical injury is a critical first step in identifying potential non-accidental trauma.
2
Determine the legal and ethical responsibility of the nurse in this situation.
The nurse recognizes the obligation as a mandated reporter to report reasonable suspicions of child abuse.
Healthcare professionals are required by law to report suspected abuse; absolute proof is not required to make a report.
3
Select the safest and most appropriate immediate intervention.
The nurse chooses to escalate the concern to the charge nurse and follow official reporting protocols without alerting the parents.
This ensures the child's safety, complies with legal mandates, and allows trained professionals (such as child protective services) to investigate.

Anahtar Kavram

Mandated Reporting and Abuse Recognition
Soru 1716Soru →

A practical nurse is providing care to several clients who are experiencing emotional distress. Match each client's clinical presentation or statement to the most appropriate therapeutic communication technique the nurse should implement initially.

Soldaki öğeye tıklayın, sonra eşleşen sağdaki öğeye tıklayın

Öğeler

A client scheduled for an invasive diagnostic test is pacing the room, wringing their hands, and breathing rapidly.
A client who recently received a terminal prognosis sits silently on the edge of the bed with tears rolling down their face.
A client asks, "Should I agree to the aggressive treatment my doctor recommends, or should I just go to hospice like my son wants?"
A client states, "Every time I try to explain my fatigue to my partner, we end up in a terrible argument."

Eşleşmeler

Cevabı ve açıklamayı göster

Cevap

The correct matches align the client's psychosocial presentation with the therapeutic technique that best addresses their immediate emotional need: pacing and wringing hands matches with making observations; silent crying matches with offering self; asking for advice on treatment matches with reflecting; and mentioning relationship arguments matches with exploring.
Therapeutic communication requires selecting the technique that best fits the client's current emotional and cognitive state. Making observations addresses visible anxiety safely; offering self supports the silently grieving client; reflecting helps a conflicted client analyze their own choices; and exploring delves into interpersonal stressors.

Adım Adım Çözüm

1
Analyze the pacing, rapidly breathing client.
Identified as demonstrating acute anxiety.
Making observations is the best technique to acknowledge nonverbal anxiety cues without forcing a severely anxious client to explain themselves.
2
Analyze the silently crying client.
Identified as experiencing shock or acute grief.
Offering self provides vital emotional support and a therapeutic presence for a client who does not yet have the words to express their distress.
3
Analyze the client asking what treatment they should choose.
Identified as experiencing decisional conflict and seeking advice.
Reflecting returns the focus to the client's own feelings and values, avoiding the nontherapeutic trap of making life decisions for the client.
4
Analyze the client mentioning recurring arguments with their partner.
Identified as introducing a specific interpersonal stressor.
Exploring helps gather more detailed information about the conflict, allowing the client to process the specific relationship dynamic.

Anahtar Kavram

Therapeutic Communication Techniques in Psychiatric and Medical-Surgical Settings
Soru 1717Soru →

An older adult client who adheres to traditional Orthodox Jewish beliefs is receiving inpatient rehabilitation following a total knee arthroplasty. Which actions by the practical nurse demonstrate culturally congruent care? Select all that apply.

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Cevabı ve açıklamayı göster

Cevap: Verifying that meat and dairy items are served on separate meal trays.; Requesting that a same-sex unlicensed assistive personnel help the client with showering.; Allowing the client to wear a traditional head covering during non-sterile rehabilitation activities.

Cevap

The correct actions are verifying that meat and dairy are served separately, requesting same-sex hygiene assistance, and allowing the client to wear a traditional head covering.
Culturally congruent care for an Orthodox Jewish client includes adhering to kosher dietary laws, which strictly prohibit the mixing of meat and dairy products on the same tray. Modesty is highly valued, so care provided by a same-sex healthcare worker is typically preferred and should be accommodated when possible. Additionally, wearing a head covering is a sign of religious reverence and should be permitted during routine, non-sterile activities like physical therapy.

Adım Adım Çözüm

1
Identify the client's cultural and religious background from the clinical scenario.
The client adheres to traditional Orthodox Jewish beliefs.
Cultural and religious beliefs significantly impact dietary preferences, modesty standards, and daily practices.
2
Determine the dietary restrictions and rules associated with the Orthodox Jewish faith.
Kosher dietary laws forbid the mixing of meat and dairy products in the same meal, and certain animal products are prohibited entirely.
Ensuring culturally appropriate meals prevents nutritional deficits and honors the client's values.
3
Evaluate the client's likely preferences regarding modesty and religious artifacts.
Same-sex care providers are strongly preferred for physical touch, and wearing a head covering (such as a kippah or yarmulke) is an ongoing religious practice.
Respecting modesty and religious artifacts builds trust and maintains the therapeutic nurse-client relationship.
4
Review the proposed nursing interventions and eliminate those that use non-therapeutic communication or violate established cultural rules.
Asking 'why' questions and serving turkey with cheese are identified as inappropriate and non-therapeutic actions.
These specific actions demonstrate a lack of cultural awareness and violate basic transcultural nursing principles.

Anahtar Kavram

Culturally Congruent Care for Orthodox Jewish Clients
Soru 1718Soru →

A 28-year-old client who is 14 hours postpartum following a forceps-assisted vaginal delivery calls for assistance, reporting severe, unrelenting vaginal and rectal pressure. The client states, "I feel like I am bleeding heavily." The practical nurse (PN) assesses the client and finds a perineal pad, which was changed 45 minutes ago, saturated with bright red blood. The fundus is firm, midline, and at the umbilicus. Current vital signs are: heart rate 118 bpm, respirations 22/min, and blood pressure 102/68 mm Hg. Based on these data, which action is the priority for the PN?

Cevabı ve açıklamayı göster

Cevap: Report the assessment findings to the registered nurse immediately for evaluation of a potential laceration or hematoma.

Cevap

Report the assessment findings to the registered nurse immediately for evaluation of a potential laceration or hematoma.
The client is presenting with bright red bleeding, a perineal pad saturated in under an hour, severe rectal and vaginal pressure, and borderline tachycardia. Crucially, the fundus is firm and midline. Heavy bleeding in the presence of a contracted (firm) uterus strongly suggests a laceration of the genital tract or a developing hematoma, especially following an operative (forceps-assisted) delivery. The tachycardia is a subtle, early sign of compensatory shock. The PN must immediately report these findings to the registered nurse (RN) or provider, as this is an emergent complication requiring advanced medical assessment and intervention that falls outside the PN scope of practice.

Adım Adım Çözüm

1
Analyze the source of bleeding by correlating the saturated pad with the tone of the fundus.
The fundus is firm and midline, meaning the heavy bright red bleeding is not caused by uterine atony.
Bleeding in the presence of a firmly contracted uterus points to another source, such as a vaginal or cervical laceration.
2
Evaluate the client's subjective symptoms and vital signs in the context of the delivery method.
The client had a forceps-assisted delivery and now reports severe vaginal/rectal pressure, accompanied by a borderline elevated heart rate of 118 bpm.
Operative vaginal deliveries increase the risk of perineal trauma. Severe pressure indicates a rapidly expanding hematoma, and tachycardia is an early compensatory sign of hypovolemic shock.
3
Determine the appropriate nursing intervention based on the Practical Nurse (PN) scope of practice.
The PN must escalate the findings to the Registered Nurse (RN) or healthcare provider.
The client is experiencing a potentially life-threatening complication that requires advanced assessment, medical diagnosis, and interventions (like suturing or IV medication titration) that fall outside the PN scope.

Anahtar Kavram

Postpartum Hemorrhage Differentiation and PN Scope of Practice
Tahmini Süre:1m 30s
Soru 1719Soru →

An agitated client paces the hallway of a behavioral health facility and approaches the practical nurse. The client points to an empty corner and speaks rapidly, stating, "The walls are starting to breathe again. The provider promised the new medication would stop this, but the shadows are stretching out and they are coming to take me away tonight." Which response by the nurse represents the most appropriate therapeutic communication technique?

Cevabı ve açıklamayı göster

Cevap: I do not see the walls breathing or any shadows moving, but I can see that you are terrified. I will stay right here with you.

Cevap

The response stating that the nurse does not see the walls breathing or shadows moving, acknowledging the client's terror, and offering to stay with them is the correct choice.
The correct response effectively utilizes three crucial therapeutic techniques for an actively psychotic client: presenting reality, validating feelings, and offering self. By explicitly stating that the nurse does not see the walls breathing or shadows moving, the nurse anchors the interaction in objective reality without arguing. Acknowledging that the client is terrified validates the intense emotional experience caused by the hallucination. Finally, offering to stay with the client provides the immediate safety and emotional support required during an acute psychiatric crisis.

Adım Adım Çözüm

1
Analyze the client's current clinical and emotional state.
The client is actively experiencing visual hallucinations and severe fear/paranoia, requiring immediate grounding and safety.
Identifying the nature of the distress is required to select a communication technique that prioritizes safety without reinforcing pathology.
2
Evaluate the communication options against established mental health therapeutic techniques.
Exploring the details of the hallucination reinforces it. Offering protection validates the threat. Arguing logic dismisses the client's reality. Presenting reality while offering self is the standard of care.
Therapeutic communication in psychiatric care requires a delicate balance of maintaining reality while demonstrating profound empathy for the emotion caused by the delusion or hallucination.
3
Select the response that safely anchors the client to reality while addressing their emotional distress.
The response that clearly states the nurse's reality, validates the client's fear, and offers physical presence is the optimal choice.
This intervention provides safety and emotional support without crossing the boundary into validating psychotic symptoms.

Anahtar Kavram

Therapeutic Communication during Acute Psychosis
Soru 1720Soru →

An 82-year-old client is admitted to the medical-surgical unit for treatment of urosepsis. The client has a documented baseline of early-stage Alzheimer's disease but is typically oriented to person and place. During the night shift, the client suddenly becomes highly agitated, insists that spiders are crawling on the bedsheets, and repeatedly pulls at their intravenous (IV) tubing. The client's temperature is 101.4°F (38.6°C). Which action should the practical nurse (PN) take first?

Cevabı ve açıklamayı göster

Cevap: Conceal the intravenous insertion site with a tubular elastic bandage and remain in the room with the client.

Cevap

Conceal the intravenous insertion site with a tubular elastic bandage and remain in the room with the client.
The client is experiencing acute delirium, likely precipitated by the systemic infection (urosepsis) and elevated temperature. The sudden onset of visual hallucinations and agitation creates an immediate safety risk regarding the disruption of essential medical equipment. The priority is to protect the IV line using the least restrictive method available. Concealing the IV site removes the visual stimulus that prompts the confused client to pull on the tubing, and staying with the client provides continuous safety monitoring without the need for physical restraints.

Adım Adım Çözüm

1
Analyze the client's sudden change in behavior and sensory perception.
The acute onset of hallucinations and severe agitation, combined with a fever and an underlying infection (urosepsis), points to acute delirium rather than a progression of Alzheimer's disease.
Differentiating between acute delirium and baseline dementia is critical for determining appropriate nursing interventions and preventing missed medical complications.
2
Identify the immediate priority for the client's care.
The primary risk is the client pulling out the IV catheter, which is essential for administering antibiotics to treat the urosepsis.
Maintaining physiological integrity and patient safety are the highest priorities in this scenario.
3
Select the nursing intervention that addresses the priority using the least restrictive means.
Covering the IV site removes the visual trigger that prompts the client to pull at the line, and staying with the client ensures safety without utilizing physical or chemical restraints.
Standards of care dictate that non-pharmacological, least-restrictive alternatives must be implemented and exhausted before applying physical restraints.

Anahtar Kavram

Management of Acute Delirium and Least Restrictive Interventions
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Tüm alıştırma soruları — NCLEX-PN | Examkin