While performing a nursing assessment, the nurse says to a patient, "While growing up, most of us have heard some half-truths about sexual matters that continue to puzzle us as adults
Do any come to your mind now?" The purpose of this question is to: a. determine possible homosexuality.
b. identify sexual misinformation.
c. identify areas of sexual dysfunction for treatment.
d. introduce the topic of masturbation.
B
Misinformation about normal sex and sexuality is common. Lack of knowledge may affect the individual's sexual adjustment. Once myths have been identified, the nurse can give information to dispel the myth.
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Family assessment can be challenging and each nurse may obtain additional information regarding family structure and dynamics. What is the best way to share this information from shift to shift?
a. Create an informal family information sheet that is kept on the bedside clipboard. That way, everyone can review it quickly when needed. b. Develop a standardized reporting form for family information that is incorporated into the patient's medical record and updated as needed. c. Require that the charge nurse have a detailed list of information about each patient and family member. Thus, someone on the unit is always knowledgeable about potential issues. d. Try to remember to discuss family structure and dynamics as part of the change-of-shift report.
The physician orders potassium chloride (KCL) intravenous (IV) for the patient. The nurse administers this drug intravenous (IV) push. What will be the most likely outcome for this patient?
1. The patient will most likely experience cardiac arrest. 2. The patient will not experience adverse effects if the push was given slowly. 3. The patient will most likely experience tissue necrosis at the injection site. 4. The patient will most likely experience renal failure.
The nurse is preparing pain medications. To which patient does the nurse anticipate administering an opioid fentanyl patch?
a. A 15-year-old adolescent with a fractured femur b. A 30-year-old adult with cellulitis c. A 50-year-old patient with prostate cancer d. An 80-year-old patient with a broken hip
You are on scene with a 14-year-old girl who states that she was beaten and was forced to have sexual contact with an older man at school. Which of the following is a true statement regarding documentation?
A) It is important to document the response of the parent. B) It is important to inspect her clothing. C) It is important to document the report and contact police. D) It is important to get a statement from the abuser.