Comprehension test #2

Question 1

A client had a thrombotic cerebrovascular accident and now has flaccid hemiplegia of the right side. When can the health care team begin rehabilitation for this hospitalized client?

1. after beginning anticoagulant therapy
2. on admission to the hospital
3. when the client can work cooperatively with health care team
4. as directed by the physical therapist

Answer 1

2. On admission to the hospital

Rehabilitation for a client who has sustained a cerebrovascular accident begins at the time the client is admitted to the hospital. The first goal of rehabilitation should be to help prevent deformities. This goal is achieved through such techniques as positioning the client properly in bed, changing the client’s position frequently, and supporting all parts of the body in proper alignment. Passive ROM exercises may also be started, unless contraindicated.

Question 2

The nurse manager has assigned a nurse as the circulating nurse for a surgical abortion. The nurse has a religious objection and wishes to refuse to participate in an abortion. What should the nurse manager of the operating room do?

1. Require the nurse to do this assignment
2. Change the assignment and record the behavior on the nurse’s evaluation
3. Change the assignment without comment
4. Change the assignment to circulate but have the nurse prepare the equipment

Answer 2

3. Change the assignment without comment.

The nurse should not be required to participate in an abortion if it contradicts the nurse’s religious beliefs. The behavior should not be reflected negatively on the nurse’s evaluation. Preparing equipment and supplies for the case may be viewed as the same as circulating for the case. The nurse has a right not to participate in an abortion unless it is an absolute emergency and no one else is available to care for the client.

Question 3

A client is taking phenytoin as an anti-epileptic medication. What should the nurse instruct the client to do?

1. obtain increased iron from a pill
2. increased the calcium in the diet
3. schedule twice-yearly dental examinations
4. have yearly eye examinations

Answer 3

3. Schedule twice-yearly dental examinations

Phenytoin causes hyperplasia of the gums, and the client needs dental examinations twice a year and meticulous oral hygiene. Phenytoin therapy may contribute to a folic acid deficiency, but it is not related to iron or calcium metabolism. A need for frequent eye examinations is not related to the side effects of phenytoin, but the client should have regular eye exams as appropriate

Question 4

A client who plays football with friends is to take methotrexate orally for severe rheumatoid arthritis. What should the nurse tell the client about taking this drug? SATA

1. “This drug will slow the progression of joint damage”
2. “You should avoid the chance of becoming bruised”
3. “Plan to increase the protein in your diet”
4. “Your HCP will monitor your blood work to determine liver disease and blood count”
5. “Limit or avoid use of alcoholic drinks”
6. “Increase your fluid intake to 3,000 mL per day”

Answer 4

1. “This drug will slow the progression of joint damage”
2. “You should avoid the chance of becoming bruised”
3. “Your HCP will monitor your blood work to determine liver disease and blood count”
4. “Limit or avoid use of alcoholic drinks”

Question 5

An older adult is constipated and tells the nurse that this has not happened before. What should the nurse tell the client?

1. “Constipation is an expected problem at your age. Wait to see if this continues”
2. “You need to eat more fiber. I’ll tell the dietician”
3. “You need to drink more water. I’ll start a record so you can keep track”
4. “This may be a sign of a more serious problem; I’ll report this to your HCP”

Answer 5

4. “This may be a sign of a more serious problem; I’ll report this to your HCP”

The new onset of constipation may be a sign of a tumor or other health problems. Constipation is not an expected change of aging. Increase fiber and fluid intake is helpful with constipation, but in this case the client needs to be seen by an HCP to rule out a health problem.

Question 6

The nurse should advise which client who is taking lithium to consult with the HCP regarding a potential adjustment in lithium dosage? A client who:

1. continues work as a computer programmer
2. attends college classes
3. can now care for her children
4. is beginning training for a tennis team

Answer 6

4. is beginning training for a tennis team

A client who is beginning training for a tennis team would most likely require an adjustment in lithium dosage because excessive sweating can increase the serum lithium level, possibly leading to toxicity. Adjustments in lithium dosage would also be necessary when other medications have been added, when an illness with high fever occurs, and when a new diet begins.

Question 7

The nurse caring for a client with type 1 DM should use which report to determine how well the insulin, diet, and exercise are balanced?

1. fasting serum glucose level
2. 1-week dietary recall
3. home log of blood glucose levels
4. glycosylated hemoglobin level

Answer 7

4. glycosylated hemoglobin level

A glycosylated hemoglobin level gives the nurse data about the average blood glucose concentration over 2 to 3 months, providing a picture of the client’s overall glucose control. A fasting serum glucose level gives a picture of the client’s recent glucose level, not the overall effectiveness of the therapeutic regimen. A 1 week diet recall is not always accurate. Although a home log would provide some information about overall control and compliance, the log may not have all of the glucose levels recorded.

Question 8

The nurses have instituted a falls prevention program. Which strategy will have the highest likelihood of preventing falls?

1. putting a falls risk sign on the clients’ doors
2. having the client wear a color-coded armband
3. making rounds of the unit and clients’ rooms
4. keeping all beds in low position

Answer 8

3. making rounds of the unit and clients’ rooms

When making rounds, nurses can note a variety of risks in the clients’ rooms, in the hallways, and other areas where clients might be at risk. Using signs & color-coded armbands and keeping the bed in a low position are also useful, but making rounds offers the opportunity for nurses to intervene immediately and teach the client, family, and staff when risks are noted.

Question 9

A client is receiving a unit of packed RBC. Before the transfusion started, the client’s BP was 90/50 mm Hg, RR 100 bpm, RR 20 breaths/min, and temp 98 F. 15 mins after the transfusion starts, the client’s BP is 92/54 mm Hg, pulse 100 bpm, RR 18 breaths/min, and temp 101.4F. What should the nurse do first?

1. Stop the transfusion
2. Raise the HOB
3. Obtain a prescription for antibiotics
4. Offer the client a cool washcloth

Answer 9

1. Stop the transfusion

The nurse’s first action should be to clamp off the transfusion because the client is having a transfusion reaction. It is most important that the client not receive any more blood. Other measures may be appropriate after the blood has been stopped. The nurse should raise the HOB if the client becomes sob. There is no need for antibiotic therapy for a blood transfusion related to a temp spike. The nurse can provide a cool washcloth for a headache or fever; however, this is not a priority.

Question 10

A client is receiving opioid epidural analgesia. The nurse should notify the HCP if the client has which findings? SATA

1. BP of 80/40 mm Hg and baseline BP of 110/60 mm Hg
2. RR of 14 breaths/min and baseline RR of 18 breaths/min
3. report of crushing headache
4. minimal clear drainage on the dressing
5. pain rating of 3 on a scale of 1 to 10

Answer 10

1. BP of 80/40 mm Hg and baseline BP of 110/60 mm Hg
2. report of crushing headache
3. minimal clear drainage on the dressing

Question 11

The nurse is instructing a female client recently diagnosed with osteoporosis about health promotion activities. The client has a 20 yr history of smoking and has a sedentary life style. Which information should the nurse include in the teaching plan? SATA

1. increase calcium & vitamin D intake using dietary supplements as prescribed
2. Begin walking for 20-30 mins 5 times a week
3. join a smoking cessation program
4. add swimming to an exercise program
5. enroll in a balance training program
6. perform ROM exercises for the joints of the hand and wrist 3 times a day.

Answer 11

1. increase calcium & vitamin D intake using dietary supplements as prescribed
2. Begin walking for 20-30 mins 5 times a week
3. join a smoking cessation program
4. enroll in a balance training program

Question 12

While the nurse is caring for a multigravid client at 39 weeks gestation in active labor whose cervix is dilated to 7 cm and completely effaced at +1 station, the client says, “I need to push!” What should the nurse do next?

1. Turn the client to her left side
2. Tell her to push when she has the urge
3. Have her pant quickly during the contraction
4. Tell her to focus on an object in the room to relax

Answer 12

3. Have her pant quickly during the contraction

Panting will alleviate the client’s urge to push. The client risks edema or tearing of the cervix if pushing begins before complete cervical dilation is achieved. Although turning the client to her left side improves uteroplacental blood flow, it will have no effect on diminishing the client’s urge to push. Although focusing on an object in the room may help the client to relax, it will have no effect on diminishing the client’s urge to push due to the pressure of a fetus at +1 station.

Question 13

When teaching a client with chronic renal failure who is taking antibiotics about which signs and symptoms of potential nephrotoxicity to report, the nurse should encourage the client to promptly report which changes in the color of the urine? SATA

1. straw-colored
2. cloudy
3. smoky
4. pink
5. pale yellow

Answer 13

2. cloudy
3. smoky
4. pink

Question 14

The nurse is coaching a client with heart failure about reducing fluid retention. Which strategy will be most effective in reducing a client’s fluid retention?

1. low-sodium diet
2. walking for 20 mins 3 times a week
3. restricting fluid intake
4. elevating the feet

Answer 14

1. low-sodium diet

In clients with fluid retention, sodium restriction may be necessary to promote fluid loss. Increasing exercise will be not reduce fluid retention. Exercise will promote circulation, but it will not manage the fluid retention. Restricting fluid intake will not reduce retained fluids; increased fluids will increase urine output and promote improved fluid balance. Elevating the client’s feet helps promote venous return and fluid reabsorption but in itself will not reduce the volume of excess fluid.

Question 15

The nurse is teaching a client with DI about using desmopressin nasal spray. The therapeutic effects of desmopressin nasal spray are obtained when the client no longer has which symptom?

1. polydipsia
2. nasal congestion
3. headache
4. blurred vision

Answer 15

1. polydipsia

The therapeutic effects of desmopressin nasal spray are relief from polydipsia and control of polyuria and nocturia in the client with DI. Side effects include nasal congestion and headache. Blurred vision is not related to desmopressin.

Question 16

A client is transferred from the coronary care unit to the step-down unit. Which information should be included in the transfer report? SATA

The client:
1. needs oxygen at 2L/min
2. has a DNR prescription
3. uses the bedpan
4. has 4 grandchildren
5. has been in normal sinus rhythm for 6 hours

Answer 16

1. needs oxygen at 2L/min
2. has a DNR prescription
3. uses the bedpan
4. has been in normal sinus rhythm for 6 hours

Question 17

A multigravid client at 26 weeks gestation with a history of pregnancy-induced hypertension (PIH) asks the nurse about traveling from North America to a village in India by airplane to visit her father, who wishes to see her before she gives birth. Which response by the nurse is most appropriate?

1. “Air travel at this point in your pregnancy can lead to preterm labor.”
2. “You can travel by airplane as long as you take frequent walks during the trip.”
3. “You need to avoid traveling because of your history of PIH.”
4. “You would be placing yourself and your fetus at risk for communicable disease common in India.”

Answer 17

3. “You need to avoid traveling because of your history of PIH.”

Traveling is not advised because of the client’s history of PIH. The client may be in jeopardy if complications occur and medical care is not available. In some cases, insurance companies will not cover costs of medical care in foreign countries. Air travel is not associated with preterm labor, although some airlines advise clients who are at 28 weeks’ gestation or beyond not to travel by air. Any travel that causes fatigue should be avoided. Additionally, any pregnant client should get frequent exercise while traveling to avoid venous stasis from prolonged sitting. The client is not at greater risk for communicable diseases. The priority is the client’s history PIH, which, if it occurs, could lead to complications.

Question 18

The nurse is providing discharge instructions to the client with peripheral vascular disease. The nurse should include which information in the discussion with this client? SATA

1. avoid prolonged standing and sitting
2. limit walking so as not to activate the “muscle pump”
3. keep extremities elevated on pillows
4. keep the legs in a dependent position
5. use a heating pad to promote vasodilation

Answer 18

1. avoid prolonged standing and sitting
2. keep extremities elevated on pillows

Elevating the extremities counteracts the forces of gravity and promotes venous return and reduces venous stasis. Walking is encouraged to activate the muscle pump and promote collateral circulation. Prolonged sitting and standing lead to venous stasis and should be avoided. Although heat promotes vasodilation, use of a heating pad is to be avoided to reduce the risk of thermal injury secondary to diminished sensation.

Question 19

A father tells the nurse that his adolescent son spends lots of time in his room, his grades are falling, and has given away a few of his favorite video games. What is the most appropriate action for the nurse?

1. Give the father the telephone number for the local crisis hotline
2. Have the father take the adolescent to the nearest mental health outpatient facility now.
3. Make a same-day appointment for the adolescent with his usual HCP
4. Obtain more history information from the distraught father before making a decision.

Answer 19

3. Make a same-day appointment for the adolescent with his usual HCP

These behaviors suggest that the adolescent is thinking of suicide. Because of these behaviors, it is imperative for the adolescent to see his HCP asap to determine whether he has suicidal thoughts. After the nurse makes the appointment, then it would be appropriate to obtain more information. Giving the father the telephone number for the local crisis hotline is appropriate after the appointment is made, to ensure that the father has additional support should the adolescent’s behavior escalates and an emergency arises. Taking the adolescent to the nearest mental health outpatient facility now is not warranted unless the adolescent’s behavior escalates.

Question 20

A school-age child is admitted to the hospital with acute rheumatic fever with chorea-like movements. Which eating utensil should the nurse remove from the meal tray?

1. fork
2. spoon
3. plastic cup
4. drinking straw

Answer 20

1. fork

For a child with chorea-like movements, safety is of prime importance. Feeding the child may be difficult. Forks should be avoided because of the danger of injury to the mouth and face with tines. Spoons, straws, and plastic cups post little risk.

Question 21

The nurse teaches the client with anxiety about the appropriate use of lorazepam. Which statement indicates that the client understands the nurse’s teaching?

1. “I can take my medicine whenever I feel anxious”
2. “It’s okay to double my dose if I need to”
3. “My medicine isn’t for the everyday stress of life”
4. “It’s safe to have a glass of wine while taking this medicine”

Answer 21

3. “My medicine isn’t for the everyday stress of life”

Question 22

The nurse is participating in a BP screening event. After 3 separate reading taken at least 2 minutes apart, the nurse determines that a client has a BP of 160/90 mm Hg. What should the nurse advise the client to do?

1. have bp evaluated again within 1 month
2. begin an exercise program
3. examine lifestyle to decrease stress
4. schedule a complete physical immediately

Answer 22

1. have bp evaluated again within 1 month

The client with systolic bp of 160 to 179 mm Hg should be evaluated by a HCP within 1 month of the screening. The client with a diastolic bp of 90 to 99 mm Hg should be rechecked within 2 months. Exercise and stress reduction may be desirable activities, but it is first necessary to evaluate the cause of elevated bp. In the absence of other symptoms, it is not necessary to have the client evaluated immediately.

Question 23

A client with acute psychosis has been taking haloperidol for 3 days. When evaluating the client’s response to the medication, which comment reflects the greatest improvement?

1. “I know these voices aren’t real, but I’m still scared of them”
2. “I’m feeling so restless, and I can’t sit still”
3. “Boy, do I need a shower. I think it’s been days since I’ve had one”
4. “I’m ready to talk about my discharge medications”

Answer 23

1. “I know these voices aren’t real, but I’m still scared of them”

Knowing that the voices are not real is a reflection that the haloperidol is effective in decreasing psychosis. Restlessness may be a side effect of haloperidol, not an indication of improvement. Awareness of need for activities of daily living is an indicator of improvement. However, recognizing that the voices are not real demonstrates a greater awareness of the client’s disorder than the need for hygiene does. Wanting to prepare for discharge before stabilization reflects denial of illness.

Question 24

A nurse is teaching a parenting class about how to prevent thrush (oral candidiasis). Which statement by a parent indicates more teaching is required?

1. “I will sterilize pacifiers”
2. “I should rinse my child’s mouth after using a corticosteroid”
3. “If my child uses a spacer with asthma medications, I need to rinse it after each use”
4. “I should rinse my child’s glass after each use”

Answer 24

4. “I should rinse my child’s glass after each use”

A new glass should be used each time the child wants a drink. Thrush is a fungal infection. Children who regularly use a corticosteroid inhaler, use oral corticosteroids, or have received antibiotics disturbing normal flora are at risk. It can also occur chronically in children who have an immune disorder. To prevent reinfection, parents should sterilize bottle nipples and pacifiers. Children with asthma should rinse their mouth well with water after using a corticosteroid, and if a spacer is used, it also needs to be rinsed.

Question 25

A 10 yr old with a history of recent respiratory infection has swelling around the eyes in the morning and dark urine. What question should the nurse ask first?

1. “Has the child had a rash & fever?”
2. “Has the child had a sore throat?”
3. “Does the child have any allergies?”
4. “Does the child drink lots of liquids?”

Answer 25

2. “Has the child had a sore throat?”

In conjunction with the child’s history of recent respiratory infection and report of dark urine, swelling around the eyes should lead the nurse to suspect acute glomerulonephritis. Therefore, the nurse should ask about a recent sore throat because a child with glomerulonephritis typically would have had a sore throat in the past 10 days. Drinking lots of liquid is unrelated to the periorbital edema.

Question 26

A client is hearing voices that are telling her to kill herself. She demands a knife to use on her wrists. The nurse calls for another team member to come to the room and provide assistance. Which is most appropriate intervention for the nurse to implement next?

1. Put the client in restraints after giving an IM dose of PRN medication
2. Ask the client to talk about her anger and what is causing it
3. Give oral PRN doses of haloperidol and lorazepam as prescribed
4. Search the client’s room for potential weapons after locking the unit kitchen.

Answer 26

3. Give oral PRN doses of haloperidol and lorazepam as prescribed

Haloperidol and lorazepam together decrease hallucinations and agitation, thus decreasing the risk of self-harm. Putting the client in restraints is premature because danger is not imminent. Asking the client to talk about her anger is inappropriate because the client is beyond rational conversation. A room search is appropriate only after the crisis with the client is handled.

Question 27

The nurse gave the client the wrong medication. It is 2 hours later when the nurse realizes the error. What should the nurse do first?

1. Assess the client’s condition
2. Notify the HCP of the error
3. Complete an incident report
4. Report the error to the unit manager

Answer 27

1. Assess the client’s condition

The nurse’s first response to the error is to assess the client for any untoward reactions as a result of the error. Notifying the HCP and unit manager of the error as well as completing an incident report are all appropriate later actions, but the first action is to assess the client.

Question 28

A neonate circumcised with a Plastibell 1 hour ago is brought to his mother for feeding. What should the nurse instruct the mother to do?

1. read a pamphlet about circumcision care
2. remove the petroleum jelly gauze in 24 hours
3. tell the nurse when the neonate voids
4. place petroleum jelly over the site every 2 hours

Answer 28

3. tell the nurse when the neonate voids

The nurse should instruct the mother to report the first voiding after the circumcision because edema could cause a urinary obstruction. Although reading a pamphlet about circumcision care may be helpful, it may not be appropriate for all mothers. Some mothers could have difficulty reading or understanding the information. Petroleum jelly gauze is used with Gomco clamp circumcisions, not Plastibell. Petroleum jelly should not be used with Plastibell circumcision methods because the bell prevents further bleeding.

Question 29

The nurse is assessing a client who has benign prostatic hypertrophy (BPH). The nurse should determine if the client has which symptom?

1. impotence
2. flank pain
3. difficulty starting the urinary stream
4. hematuria

Answer 29

3. difficulty starting the urinary stream

The symptoms of BPH are related to obstruction as a result of an enlarged prostate. Difficulty in starting the urinary stream is a common symptom, along with dribbling, hesitancy, and urinary retention. Impotence does not result from BPH. Flank pain is most commonly related to pyelonephritis. Hematuria occurs in UTI, renal calculi, and bladder cancer, to name some of the most common causes.

Question 30

The nurse is assessing a client with dark skin who has early signs of iron deficiency anemia. Which is the expected color of this client’s skin?

1. reddish-brown
2. yellowish-brown
3. black-brown
4. whitish-brown

Answer 30

2. yellowish-brown

One of the early signs of iron deficiency anemia in a client of Vietnamese descent with dark skin is yellowish-brown skin tones. The nurse can assess for petechiae or jaundice, which may be observed in the conjunctiva or buccal mucosa.

Question 31

The client is having peritoneal dialysis. During the exchange, the nurse observes that the flow of dialysate stops before all the solution has drained out. What should the nurse do next?

1. Have the client sit in a chair
2. Turn the client from side to side
3. Reposition the peritoneal catheter
4. Have the client walk

Answer 31

2. Turn the client from side to side

Fluid return with peritoneal dialysis is accomplished by gravity flow. Actions that enhance gravity flow include turning the client from side to side, raising the hob, and gently massaging the abdomen. The client is usually confined to a recumbent position during the dialysis. The nurse should not attempt to reposition the catheter.

Question 32

Which type of restraints is best for the nurse to use for a child in the immediate postoperative period after cleft palate repair?

1. safety jacket
2. elbow restraints
3. wrist restraints
4. body restraints

Answer 32

2. elbow restraints

Recommended restraints for a child who has had palate surgery are elbow restraints. They minimize the limitation placed on the child but still prevent the child from injuring the repair with fingers and hands. A safety jacket or wrist or body restraints restrict the child unnecessarily.

Question 33

Which nursing goal is appropriate for the nurse to make with a client who has multiple myeloma?

1. achieve effective management of bone pain
2. recover from the disease with minimal disabilities
3. decrease episodes of nausea and vomiting
4. avoid hyperkalemia

Answer 33

1. achieve effective management of bone pain

In multiple myeloma, neoplastic plasma cells invade the bone marrow and begin to destroy the bone. As a result of this skeletal destruction, pain can be significant. There is no cure for multiple myeloma. N&V are not characteristics of the disease, although the client may experience anorexia. The client should be monitored for signs of hypercalcemia resulting from bone destruction, not for hyperkalemia.

Question 34

A young adult has been diagnosed with hypertrophic cardiomyopathy. The nurse should further assess the client for which complication?

1. angina
2. fatigue & sob
3. abdominal pain
4. hypertension

Answer 34

2. fatigue & sob

Cardiomyopathy is a broad term that includes 3 major forms: dilated, hypertrophic, and restrictive cardiomyopathies. The underlying etiology of hypertrophic cardiomyopathy is unknown; it is typically observed in young men but is not limited to them. Common symptoms are fatigue, low tolerance to activity related to the low ejection fractions, and sob. Angina may be observed if coronary artery disease is present. Abdominal pain and hypertension are not common.

Question 35

Which finding provides the most evidence that a fetus might have a GI tract anomaly?

1. meconium in the amniotic fluid
2. low implantation of the placenta
3. increase amount of amniotic fluid
4. preeclampsia in the last trimester

Answer 35

3. increase amount of amniotic fluid

Maternal hydramnios occurs when the fetus has a congenital obstruction of the GI tract, such as in the presence of a tracheoesophageal fistula. The fetus normally swallows amniotic fluid and absorbs the fluid from the GI tract. Excretion then occurs through the kidneys and placenta. Most fluid absorption occurs in the colon. Absorption cannot occur when the fetus has a Gi obstruction. Meconium in the amniotic fluid, low implantation of the placenta, and preeclampsia could occur but are more specifically associated with fetal hypoxia.

Question 36

A 17 yr old gang member, who is living on the streets, is hospitalized after an overdose. When medically stable, the teen is admitted to the adolescent psychiatric unit of the same hospital. In what order of priority from first to last should the nurse explore the issues? All options must be used.

1. the reason the teen is not living with parents
2. the desire to leave or remain in the gang
3. the current level of suicidal risk
4. the desire to return home or go elsewhere after discharge

Answer 36

3. the current level of suicidal risk
4. the desire to leave or remain in the gang
5. the desire to return home or go elsewhere after discharge
6. the reason the teen is not living with parents

Question 37

A nurse is relieving the triage nurse in the L&D unit who is going to lunch. The report indicates that there are 3 clients having their vital signs assessed and a 4th client is on her way to the unit from the ED. In which order or priority from first to last should the nurse manage these clients? All options must be used.

1. the client with clear vesicles and brown vaginal discharge at 16 weeks gestation
2. the client with RLQ pain at 10 weeks gestation
3. the client who is at term and has had no fetal movement for 2 days
4. the client from the ED at term and screaming loudly because of labor contractions

Answer 37

4. the client from the ED at term and screaming loudly because of labor contractions
5. the client with RLQ pain at 10 weeks gestation
6. the client with clear vesicles and brown vaginal discharge at 16 weeks gestation
7. the client who is at term and has had no fetal movement for 2 days

Question 38

The nurse on the postpartum unit is caring for 4 couplets. There will be a new admission in 30 mins. The new client is a G4 P4, Spanish-speaking only client with an infant who is in the SCN for respiratory distress. The nurse should place the new client in a room with which client?

1. a G4P4 which is 2 days postpartum with infant, Spanish speaking only
2. a G1P1 who is 1 day postpartum with an infant in the SCN
3. a G6P6 who have birth 4 hours ago by c-section for fetal distress, infant at bedside
4. a G1P1 who is a non-English-speaking client with infant in SCN for fetal distress

Answer 38

1. a G4P4 which is 2 days postpartum with infant, Spanish speaking only

The ability to communicate with a person of the same language would be an advantage, an opportunity for socialization and support for the new mother who speaks Spanish. If a Spanish-speaking mother were placed with the client who also had a baby in SCN, she would have no communication opportunity, and the same would apply for rooming with the mother who has had a c-section. The client who is non-English speaking does not identify the language spoken, and the nurse cannot assume that it is Spanish.

Question 39

Which client is at greatest risk for falling?

1. a 22 yr old man with 3 fractured ribs and a fractured left arm
2. a 70 yr old woman with episodes of syncope
3. a 50 yr old man with angina
4. a 30 yr old woman with a fractured ankle

Answer 39

2. a 70 yr old woman with episodes of syncope