A nurse enters a family's home for the first time. Which of the following goals should the nurse have? (Select all that apply.)
a. Assessing each family member in detail both physically and psychologically
b. Collaborating with the family to establish goals and a plan for meeting them
c. Determining the exact relationship between each member of the family
d. Exploring the family's perception of their problems and needs
ANS: B, D
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While palpating the nail bed of an African American client, the nurse notes that the client's nails have linear bands along the nail edge. This finding:
1. Is found in dark-skinned individuals. 2. Indicates a fungal infection of the nail bed. 3. Indicates a nutritional deficiency. 4. Indicates the client is cyanotic.
The nurse caring for a client experiencing back pain, nausea, and fatigue inquiries about current stressors. The client states, "I am sick. Why are you asking me about all of this stress stuff?" Which information should the nurse provide the client?
A. "Your nausea and fatigue are most often related to increase of stress in life." B. "I am assessing your ability to cope with additional stressors." C. "Screening for stress is required for every client." D. "Stress can impact our body by producing a variety of symptoms."
The client asks the nurse which type of diabetes is caused by a lack of insulin secretion by the pancreas. What is the best response by the nurse?
1. "Type 2 diabetes" 2. "Both type 1 and type2 diabetes" 3. "Type 1 diabetes" 4. "Neither—they both result from the inability of the body to use insulin"
A patient with chest pain is a candidate for thrombolytic therapy. How soon should this medication be provided to the patient?
a. 30 minutes b. 120 minutes c. 180 minutes d. 240 minutes