Questions and Answers
What should the nurse do next when an unemancipated minor requests treatment?
What is the most appropriate response by the nurse when an LPN assigned to a client with localized herpes zoster states they have never had chickenpox?
Which client should the nurse see first?
What statements should the nurse include when responding to a patient concerned about a bone marrow aspiration and biopsy?
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What is the best response by the nurse when a spouse states, 'You never take any responsibility for the messes you always cause'?
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Which actions should the nurse include in the plan of care for a patient with a gastrostomy tube?
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Which statement made by the patient is most concerning regarding potential spousal abuse?
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Study Notes
ED Triage and Unemancipated Minor
- Unemancipated minors may consent to treatment for certain medical conditions such as pregnancy, STIs, substance abuse, and mental health issues.
- The nurse should first assess the minor's medical reason for seeking treatment before any further actions.
Caring for Clients with Localized Herpes Zoster
- Localized herpes zoster (shingles) poses a risk of exposing unvaccinated individuals to chickenpox.
- Standard precautions are crucial, and potential changes in assignments may be necessary based on staff concerns regarding exposure risks.
Prioritizing Pregnant and Postpartum Patients
- Bloody discharge (rubra lochia) in postpartum patients should last only 1-3 days; any bright red discharge after 5 days is concerning.
- Fetal heart tones cannot be detected until at least 8-12 weeks gestation, and less than 3 fetal movements in an hour may indicate concern for fetal wellbeing.
Bone Marrow Aspiration and Biopsy
- Bone marrow aspiration can be performed in the patient’s room, not exclusively in an OR setting.
- A tight pressure dressing is important after the procedure to manage potential bleeding, and monitoring for bleeding post-test is essential.
- Patients may feel discomfort during local anesthetic injection, which should be communicated prior to the procedure.
Couples Counseling Dynamics
- Blame can be counterproductive in relationship discussions; addressing communication patterns can be more effective.
- Statements that suggest one partner feels solely responsible may indicate deeper issues in communication and relationship dynamics.
Enteral Feedings through Gastrostomy Tube
- The insertion site should be covered with a sterile bandage initially to prevent infections.
- Only 4 hours of formula should be added at a time to minimize the risk of bacterial growth in the feeding bag.
- Daily rotation of the gastrostomy tube helps prevent skin irritation, while slight movement indicates that the tube is properly placed.
Assessing for Potential Spousal Abuse
- Victims of spousal abuse often express self-blame, which can be a red flag for ongoing abuse.
- Statements indicating unhappiness and disputes in the relationship may also require further assessment, but direct blame is of the highest concern.
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Test your knowledge with this NCLEX RN practice test featuring essential scenarios and questions at the passing level. Perfect for nursing students preparing for the exam. Each flashcard is designed to help reinforce your understanding of critical nursing concepts.
