The nurse is completing her plan of care for a patient with congestive heart failure. In performing a direct-care nursing intervention the nurse will:
a. Collaborate with the physician for further medication orders
b. Instruct the patient about low sodium and low fat diets
c. Refer the patient to the cardiac rehabilitation program for a home-care exercise program
d. Consult with physical therapist for cardiac rehabilitation exercises
B
Direct-care interventions are performed through interactions with the client. Examples are physical care, emotional support, and teaching. An indirect-care intervention is an activity performed away from the client on behalf of the client. Indirect-care interventions include consulting with other healthcare team members, making referrals, advocating, and managing the environment.
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A client who tests positive for a mutation in the BRCA1 gene allele asks a nurse to be present when she discloses this information to her adult daughter. How should the nurse respond?
a. "I will request a genetic counselor who is more qualified to be present for this conversation." b. "The test results can be confusing; I will help you interpret them for your daughter." c. "Are you sure you want to share this information with your daughter, who may not test positive for this gene mutation?" d. "This conversation may be difficult for both of you; I will be there to provide support."
If a child has a headache described as migraine-like and also has a seizure, the nurse should have a high suspicion of:
a. ruptured cerebral aneurysm c. astrocytoma b. arteriovenous malformation d. hydrocephalus
On returning from surgery after undergoing a thyroidectomy, a patient is alarmed about the large tracheostomy tray on the bedside table. What is the nurse's most reassuring response when the patient asks why it is there?
a. "We have it there as a precautionary measure in the unlikely event that you have difficulty breathing." b. "If you start bleeding, we'll be able to take care of it right here at the bedside." c. "We have to keep it there in case of an emergency and the physician needs it." d. "It's hospital policy to have it available for persons who are likely to have respiratory arrest."
A patient has been taking an AED for several years as part of his treatment for partial seizures. His wife has called b
ecause he ran out of medication this morning and wonders if he can go without it for a week until she has a chance to go to the drugstore. What is the nurse's best response? a. "He is taking another antiepileptic drug, so he can go without the medication for a week." b. "Stopping this medication abruptly may cause withdrawal seizures. A refill is needed right away." c. "He can temporarily increase the dosage of his other antiseizure medications until you get the refill." d. "He can stop all medications because he has been treated for several years now."