nova southeastern university| maternity safety exam| complete solutions| verified answers complete with rationale
nova southeastern university| maternity safety exam| complete solutions| verified ans
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Nova Southeastern University| Maternity Safety Exam| Complete Solutions| Verified Answers Complete with Rationale.
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Question 1 See full question
A 15-year-old adolescent confides in the nurse that he has been contemplating suicide. He says
he has developed a specific plan to carry it out and pleads with the nurse not totell anyone. What
is the nurse's best response?
Your Answer:
• "For your protection, I can't keep this secret. After I notify the physician, we willneed
to involve your family. We want you to be safe."
Correct Answer:
• "For your protection, I can't keep this secret. After I notify the physician, we willneed
to involve your family. We want you to be safe."
Explanation:
In situations in which a client is a threat to himself, the nurse can't honor confidentiality.
Because this adolescent has said he has a specific plan to commit suicide, the nurse must take
immediate action to ensure his safety. The physician and mental health professionals should be
notified as well as the client's family. The nurse should inform the adolescent that she must do
this, while at the same time conveying a sense of caring and understanding. The local
authorities needn't be notified in this situation.
Remediation:
Question 2 See full question
As a client is being released from restraints, he says, "I'll never get that angry and lose itagain.
Those restraints were the worst things that ever happened to me." Which response by the nurse is
most appropriate?
Your Answer:
• "I'd like to talk with you about your experience."
Correct Answer:
• "I'd like to talk with you about your experience."
Explanation:
After a client is released from restraints, he and the nurse need to process the experience by
discussing why restraints were used and any other information the clientwishes to discuss.
Asking the client if he means what he says challenges or questions the validity of his statement.
Simple reflection of the client's words may not open up discussion about the experience.
Telling the client that the experience won't bother himin the future is judgmental and trivializes
the client's remark.
Remediation:
,Question 3 See full question
Which instruction should a nurse include in an injury-prevention plan for a pregnantclient?
Your Answer:
• "Take rest periods during the day."
Correct Answer:
• "Take rest periods during the day."
Explanation:
The client should be instructed to avoid becoming fatigued and to take rest periods during the
day. Fatigue can lead to injuries. The nurse should instruct the client to wear a seat belt below
the tummy, not across it, and to position the steering wheel toward herchest, not her abdomen, to
prevent injury to the fetus. Learning a new activity or sport while pregnant can lead to injury.
Remediation:
Question 4 See full question
A client with stage II Alzheimer's disease is admitted to the short stay unit after cardiac
catheterization that involved a femoral puncture. The client is reminded to keep his legstraight.
A knee immobilizer is applied, but the client repeatedly attempts to remove it. The nurse is
responsible for three other clients who underwent cardiac catheterization.What's the best step
the nurse can take?
Your Answer:
• Ask the staffing coordinator to assign a nursing assistant to sit with the client.
Correct Answer:
• Ask the staffing coordinator to assign a nursing assistant to sit with the client.
Explanation:
The nurse should ask the staffing coordinator to assign a nursing assistant to sit with the client.
This action promotes client safety while avoiding restraint use. Applying wristrestraints doesn't
prevent injury to the lower leg. Also, restraints should be applied onlyafter other less restrictive
measures have been attempted. A client with stage II Alzheimer's disease has memory
impairment that impedes his ability to remember repeated instruction. Sedation isn't indicated
for this client.
Remediation:
Question 5 See full question
,A client diagnosed with schizophrenia for the last 2 years tells the nurse who has brought the
morning medications, "That is not my pill! My pill is blue, not green." Whatshould the nurse
tell the client?
Your Answer:
• "I will go back and check the drawer as well as telephone the pharmacy to checkabout
any possible changes in the medication color."
Correct Answer:
• "I will go back and check the drawer as well as telephone the pharmacy to checkabout
any possible changes in the medication color."
Explanation:
It is important for the nurse to listen to the client and respect his or her knowledge aboutthe
medication. In the other options, the nurse dismisses the client’s concern or gives a possible
explanation without checking out the specific situation. If the nurse has taken the wrong
medication, the client can prevent a medication error, and if there has been a color change, the
nurse can let the client know that information. In either case, helping apsychotic client deal with
reality appropriately is therapeutic.
Remediation:
Question 6 See full question
The nurse is admitting a child who has been diagnosed with bacterial meningitis to the
pediatric unit. The nurse should implement which type of isolation?
Your Answer:
• droplet precautions
Correct Answer:
• droplet precautions
Explanation:
Bacterial meningitis is caused by one of three organisms, H. influenzae type
b, Neisseria meningitidis, or Streptococcus pneumoniae. All three organisms may be
transmitted through contact with respiratory droplets. These droplets are heavy and typically
fall within 3 feet (91.4 cm) of the client. Droplet precautions require, in additionto standard
(routine) precautions, that HCPs wear masks when coming into close contact with the client.
Standard or routine precautions, previously referred to as universal precautions, are general
measures used for all clients. Contact precautions are used when direct or indirect contact with
the client causes disease transmission.
Gowns and gloves are needed but not masks. Airborne precautions differ from droplet inthat the
particles are smaller and may stay suspended in the air for longer periods of
, time. These clients require negative pressure rooms, and all heath care workers mustwear
respirators.
Remediation:
Question 7 See full question
The nurse is preparing a community education program about preventing hepatitis B
infection. Which information should be incorporated into the teaching plan?
Your Answer:
• Good personal hygiene habits are most effective at preventing the spread of
hepatitis B.
Correct Answer:
• The use of a condom is advised for sexual intercourse.
Explanation:
Hepatitis B is spread through exposure to blood or blood products and through high-risksexual
activity. Hepatitis B is considered to be a sexually transmitted disease. High-risk sexual
activities include sex with multiple partners, unprotected sex with an infected individual, male
homosexual activity, and sexual activity with IV drug users. College students are at high risk for
development of hepatitis B and are encouraged to be immunized. Alcohol intake by itself does
not predispose an individual to hepatitis B, but it can lead to high-risk behaviors such as
unprotected sex. Good personal hygiene alone will not prevent the transmission of hepatitis B.
Remediation:
Question 8 See full question
A client with a suspected brain tumor is scheduled for a computed tomography (CT)scan.
What should the nurse do when preparing the client for this test?
Your Answer:
• Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
Correct Answer:
• Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
Explanation:
Because CT commonly involves use of a contrast agent, the nurse should determine whether the
client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization isnecessary only if
the client has a suspected spinal cord injury. Placing a cap over the client's head may lead to
misinterpretation of test results; instead, the hair should be
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