The nurse is drawing blood for a prenatal triple screen. How should the nurse explain this test to the client?
1. "The triple screen test looks at levels of three substances in your blood that would indicate we need to do additional testing."
2. "This test will be run three times for accuracy."
3. "This test screens for triplets."
4. "This is the first of three tests you will have, so it is called a triple screen."
1
Rationale 1: The triple screen measures levels of maternal serum alpha fetoprotein, human chorionic gonadotropin, and maternal serum unconjugated estriol. Results may indicate further testing should be done.
Rationale 2: The test is not run three times.
Rationale 3: The triple screen may be used when it is suspected the mother is carrying more than one fetus, but this is not its primary use.
Rationale 4: The triple screen is run on a single blood sample.
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A client's record contains a notation that the client is orthopneic. Which question by the nurse would obtain the most useful information?
a. "About how far can you walk before it occurs?" b. "Does anyone else in your family have this too?" c. "How many pillows do you need to sleep on?" d. "When did you first notice this problem?"
Impulse control is part of a plan for a client with borderline personality disorder. Which of the following is particularly important to include?
A) Identification of support sources B) A no-harm contract C) Management of emotions D) Identification of behavior patterns
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