An adult client with paranoid schizophrenia lives in a homeless shelter with her 13-year
old-daughter. The mother is fragile but not psychotic most of the time.
The nurse establishes a
relationship with the daughter and determines that the child has adapted to shelter life, having
formed a relationship with one of the shelter volunteers who encourages her to attend school. The
teen relates that she has a friendship with a classmate. When she describes this relationship, the
nurse determines that the teen is able to exercise both social skills and problem-solving skills. The
mobile treatment team asks the nurse to make a recommendation regarding what should be done to
assist the teenage daughter. The best recommendation would be to
a. suggest foster home placement.
b. seek assistance from the domestic violence program.
c. make referrals for existing and emerging developmental problems.
d. foster healthy characteristics and existing environmental supports.
D
Because the teenage daughter shows no evidence of poor mental health, the best action would be to
foster existing healthy characteristics and environmental supports. No other option is necessary or
appropriate under the current circumstances.
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When planning the care for a client who has a spinal cord injury, the nurse should perform which action first?
1. Testing for motor strength 2. Listening for bowel sounds 3. Palpating the client's bladder for fullness 4. Monitoring the client's blood pressure
A patient's primary care provider has indicated that her symptoms of dyspnea and fatigue related to heart failure are class IV. This classification indicates that she experiences
a. symptoms with any activity or even at rest. b. symptoms with ordinary physical activity and has a slight limitation of physical activity. c. no symptoms with ordinary physical activity. d. symptoms with ordinary physical activity and has a marked limitation of physical activity.
It is determined that a client has a large pulmonary embolism (PE). Fibrinolytic therapy is initiated. What is the nurse's priority action?
a. Monitor the client's oxygenation. b. Teach the client about potential side ef-fects. c. Monitor the IV insertion site. d. Monitor for bleeding.
The nurses at the hospital where you are employed are in the process of unionization. Your role during this process would include which of the following? Select all that apply
a. Act clearly within the law at all times. b. Know the rights of your manager. c. If a manager acts unlawfully, report it to the NLRB. d. Know your legal rights. e. Demand an increase in salary. f. If another nurse practices in an unsafe manner, report it to the NLRB.