The nurse is admitting a patient at 28 weeks' gestation to the emergency department following an episode of domestic abuse resulting in ecchymosis and lacerations. Which question is most critical to ask?
1. "What did you do to make your spouse so angry?"
2. "How many times has this happened in the past?"
3. "Do you have a safe place that you can go?"
4. "Will you be pressing charges against your spouse?"
Correct Answer: 3
Rationale 1: This statement is blaming and must be avoided to establish a trusting, therapeutic relationship with an abused patient.
Rationale 2: Although domestic abuse tends to increase in frequency and violence during pregnancy, this is not the highest priority.
Rationale 3: This question is the highest priority because having a safe place to go after leaving the hospital reduces the risk of a repeated attack and further injury to both mother and fetus.
Rationale 4: Legal issues are a low priority at this time. Physiologic issues such as safety in the future have more importance.
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You are caring for a patient on mechanical ventilation with 10 cm H2O of PEEP. The patient becomes suddenly dyspneic. The trachea is deviated toward the left and breath sounds are absent on the right. You suspect
A) atelectasis. B) tension pneumothorax. C) pulmonary edema. D) intubation of right mainstem bronchus.
With the need to protect our environment, what is it now important for the nurse to teach patients to do?
A) Dispose of drugs no longer used on an annual basis. B) Flush drugs down the toilet. C) Bury unused in the yard. D) Throw unused pill bottles in the trash in original containers.
The nurse should notify the care provider when umbilical cord assessment immediately following delivery reveals:
A) the umbilical cord is clamped one inch from the abdomen. B) the umbilical cord contains one artery. C) the umbilical cord appears moist and rubbery. D) the umbilical cord is pulsating.
Mrs. Williams is a 34-year-old mother who recently delivered her third child. She tells the nurse that her New Year's resolution is to lose the 15 pounds that she gained with this pregnancy over the next month
Which of the following is the best statement that the nurse can make to help Mrs. Williams achieve her weight loss goal? A. "I don't think you need to lose the weight; you look fine as you are." B. "The weight will come off by itself because you are breast-feeding." C. "It took you nine months to gain the weight; give yourself a realistic timeframe to lose it." D. "It is easier to lose weight if you have a realistic goal."