A 16-year-old pregnant client is seen at her 10-weeks'-gestation visit. She tells the nurse that she felt the baby move that morning. What response by the nurse is appropriate?
1. "That is very exciting. The baby must be very healthy."
2. "Would you please describe what you felt for me?"
3. "That is impossible. The baby is not big enough yet."
4. "Would you please let me see whether I can feel the baby?"
2
Explanation: 2. The nurse should ask the client to describe what she felt, as 10 weeks' gestation is too early to feel fetal movement.
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A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%. The client states, "I do not want to wear the oxygen because it causes my nose to bleed. Get out of my room and leave me alone!"
Which action should the nurse take? a. Instruct the client to sit in as upright a position as possible. b. Add humidity to the oxygen and encourage the client to wear it. c. Document the client's refusal, and call the health care provider. d. Contact the provider to request an extra dose of the client's diuretic.
A nurse in the emergency department (ED) wants to screen a patient for intimate partner violence (IPV), but the woman's partner will not leave her side. Which intervention by the nurse would be best?
a. Ask the patient the questions with the partner present, because he will not leave. b. Bluntly tell the partner he has to leave so the nurse can assess the patient. c. Have security escort the partner to the ED waiting room. d. Tell the patient she will help her collect a urine specimen in the restroom.
A patient has been living with seasonal allergies for many years, but does not take antihistamines, stating, "When I was young I used to take antihistamines, but they always put me to sleep." How should the nurse best respond?
A) "Newer antihistamines are combined with a stimulant that offsets drowsiness." B) "Most people find that they develop a tolerance to sedation after a few months." C) "The newer antihistamines are different than in years past, and cause less sedation." D) "Have you considered taking them at bedtime instead of in the morning?"
A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which of the following statements by the nurse would recognize the client's value as an individual?
A) "Can you tell me how long your father has been this way?" B) "Sarah, I have to go and read your father's old charts before we talk." C) "Mr. Koeppe, tell me what you do to take care of yourself." D) "Mr. Koeppe, I know you can't answer my questions, but it's okay."