Coordinated Care for PN II

The nurse frequently assesses the client and finds that gestational hypertension has progressed to eclampsia. The nurse is collecting assessment data from a client who is at 32 weeks’ gestation.  What finding is most important to report to the health care provider?

The licensed practical/vocational nurse (LPN/LVN) works in the labor and delivery unit with a registered nurse (RN). The following clients present to the unit. When assessing client needs, to what client will the licensed practical nurse most likely be assigned?

A nurse is caring for a client in the immediate postcardiac catheterization period. Which interventions should the nurse include in the client’s care? Select all that apply.

The nurse is mentoring a graduate practical nurse. When reviewing the steps needed to analyze an ECG rhythm strip, place the ECG analysis steps in order from first to last. All options must be used.

After assessing for physical abuse, the nurse suspects that the toddler has also been sexually abused. If the nurse suspects that a child is the victim of abuse, what nursing action is most appropriate to take initially?

If the novice nurse asks the client questions, what question would the expert nurse stress as being most important?

A client is admitted with inflammatory bowel syndrome (Crohn’s disease). Which nursing measures would be included in the client’s care plan? Select all that apply.

A nurse is preparing discharge instructions for an above-the-knee amputation client. Which instructions would be a priority? Select all that apply.  

A nurse works in a substance use disorder clinic where most clients are aged between 18 and 25 years. What resource is most appropriate for the nurse to recommend when a client’s family asks where they can support coping with a family member who suffers from alcohol use disorder?

A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation below, which laboratory result is the nurse’s priority to report to the health care provider?

A nurse is caring for a client who is being discharged after a thyroidectomy. Which discharge instructions would be appropriate for this client? Select all that apply.

The parents of a 3-year-old child with an autism spectrum disorder bring their child to a mental health clinic regularly. Currently, a care conference is planned with the mental health team and the family. When planning care for a child with an autism spectrum disorder, what nursing intervention is most appropriate?

When administering a blood transfusion to a patient, which action can help the nurse delegate to the unlicensed assistive personnel (UAP)?

While the postpartum nurse was providing shift handoff to the oncoming nurse, all of the nurse’s postpartum clients called the nurse’s station with concerns. What client will receive priority attention?

If the adolescent parent expresses feeling inexperienced and inadequate in caring for the infant, what referral is best?

A nurse is a volunteer answering telephone calls on a hotline at a crisis center. If a victim of sexual assault desires medical treatment but objects to having evidence collected for a criminal prosecution, what nursing action is most appropriate?

The school nurse is working with the teacher to provide the best educational setting for the child with attention deficit hyperactivity disorder (ADHD). What nursing intervention is most appropriate to include when preparing a care plan regarding this child’s educational setting?

After arguing with a spouse on the phone, a client becomes angry and belligerent toward the unlicensed assistive personnel (UAP) if the angry client is out of control and refuses a p.r.n. Sedative medication, what is the nurse’s legal option?

The parents of a 3-year-old child with an autism spectrum disorder bring their child to a mental health clinic regularly. Currently, a care conference is planned with the mental health team and the family. Based on the nurse’s knowledge of behavior exhibited by children with an autism spectrum disorder, what intervention is most likely a priority at the team conference?

The unlicensed assistive personnel (UAP) becomes frustrated by the 2-year-old child’s persistent “No” response whenever the child is asked to do something. The UAP asks the nurse for help. What is the best suggestion the nurse can give the unlicensed assistive personnel caring for the 2-year-old child at this time?

A 9-year-old student is frequently absent from school. When the student attends school, the student talks out of turn, fights with classmates, moves about in the classroom during a lesson and does not complete the assignments or homework. The student’s current grades are inconsistent with past performance. The school nurse plans to speak with the student to determine if there is a health problem causing these changes.

What approach is most appropriate when the school nurse speaks with the child?

A client’s pastor visits the hospital. On approaching the nurses’ station, the pastor tells the nurse that the client has been permitted to see the medical record. What nursing action is most appropriate initially?

An 18-month-old child with a diagnosis of cystic fibrosis is admitted to the hospital because of increasing respiratory difficulty and repeated respiratory infections. What is the priority nursing goal when managing the care of a child with cystic fibrosis?

The nurse has been working with a college student with bulimia, helping the client control the eating disorder. What nursing recommendation is most likely to be effective in helping the client control bulimia?

The nursing team meets to plan the care of the client with anorexia nervosa. What nursing goal is the initial priority?

The nursing team holds a conference concerning a 38-year-old client who has just been admitted with an irritable bowel syndrome, a psychophysiological disease. When did the unlicensed assistive personnel ask if psychophysiological means that the client is not truly sick? What nursing response is most accurate?

The mental health technician is frustrated and angry when seeing the client with anorexia rearranging the food on the tray but not eating any of it. What is the best guidance the nurse can provide the mental health technician to deal with the frustration?

During a team conference, the nurses discuss the care of the client with ulcerative colitis. What assessment is the nursing priority when caring for the client?

After 3 days of treatment, the child’s condition improves significantly. The health care provider writes a discharge prescription that includes instructions for home care. The parents speak some English, but their primary language is Spanish. What action is best to ensure that the parents understand the discharge instructions?

A 27-year-old foreign-born client is admitted to the mental health unit with abdominal pain thought to be psychophysiological in origin. The client is apprehensive and speaks very little of the dominant language. What translation method is best when the nurse is attempting to obtain the client’s history?

There are four major types of staffing plans. The self-scheduling method of staff planning refers to which of the following?

The nurse who admits making a medication error and immediately files an incident report is demonstrating:

Nurse managers are included in strategic planning for the institution because of which principle?

During a team conference, the nurses discuss the care of the client with ulcerative colitis. What assessment is the nursing priority when caring for the client?

While attempting to help the adolescent with cognitive impairment out of bed, the unlicensed assistive personnel is struck by the adolescent. When the nurse documents the client acting out, what wording best describes the situation?

At the beginning of the next shift, a team member states, “Do not expect me to take care of that good-for-nothing drunk.” The nurse counsels the team member privately about the inappropriate remark. What nursing recommendation is most helpful in understanding and accepting the behavior of clients?

A nurse is caring for five newborns in the nursery when an admission arrives at the change of shift. A new obstetric licensed practical nurse (LPN) informs the charge nurse that documentation on their assignment will not be completed at the end of the shift. What statement by the LPN mentor is best?

A nurse is assigned to care for a 35-year-old client who sustained a severe head injury and brain damage in a motor vehicle accident. If the client’s spitting becomes habitual, what nursing intervention is best to include in a care plan to reduce the behavior?

The behavioral outburst of the client with cognitive impairment is discussed at a team conference. What intervention would best prevent nursing personnel from becoming injured when providing the adolescent with care?

A nurse performs a home assessment on a reasonably healthy older adult who chooses to live in a supervised retirement community. If the older adult’s children are visiting on the day of the scheduled visit, what nursing action is most appropriate before beginning the assessment?

The school nurse is monitoring the diet of a child with cystic fibrosis. Which type of diet would be stressed to the family?

In teaching a group of parents about monitoring for urinary tract infection (UTI) in preschoolers, the nurse should mention which finding is most indicative of the need to have a child evaluated?

A group of nurses attends in-service training about documentation issues. The nurses critique a chart entry that says, “States, ‘I feel unwanted.’ Appears to be confused.” What statement best describes why this entry is unsatisfactory?

The nurse is caring for a 7-year-old child who fell off an all-terrain vehicle (ATV), sustaining a flesh wound. The child is awaiting wound debridement. What nursing action best demonstrates the concept of atraumatic care?

The parents express a desire to leave their child with an autism spectrum disorder with a responsible person for a few hours occasionally so that they can have relief from the responsibility of constant care and supervision. What is the most appropriate community resource for the nurse to recommend for respite services?

A 16-year-old adolescent is brought to the emergency department for the treatment of a stab wound after a gang-related fight. The adolescent is eventually ordered by the court to receive counseling at the community mental health clinic. What information is most important for the mental health nurse to communicate before each group meeting?

The educator conducts in-service training for the nursing staff on cultural considerations related to mental illness and discusses the barriers to obtaining treatment. When providing care for a newly immigrated adult client diagnosed with mental illness, what is a primary factor(s) affecting the development of a nursing plan of care? Select all that apply.

After arguing with a spouse on the phone, a client becomes angry and belligerent toward the unlicensed assistive personnel (UAP). What action is best for the nurse to initially recommend the UAP to help the angry client maintain self-control?

Family therapy is included in the counseling plan for the adolescent gang member. The client’s parent arrives late and is intoxicated. Of the following community resources, what referral is best for the nurse to suggest for this client to help address personal issues?

The nurse observes the unlicensed assistive personnel assigned to a client who just returned from having a bronchoscopy. What action by the nursing assistant would prompt the nurse to intervene?