A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take?
Contact the adolescent’s parent for assistance.
Assist the adolescent in applying for Medicaid.
Refer the adolescent to a local mental health clinic.
Advise the adolescent to place the newborn for adoption.
The Correct Answer is B
The correct answer is B.
Assist the adolescent in applying for Medicaid.
This action demonstrates the nurse’s role as an advocate and a resource person for the client, who might be eligible for financial assistance and health care coverage during her pregnancy and postpartum period. Medicaid is a federal and state program that provides health insurance for low-income individuals and families.
Choice A is wrong because contacting the adolescent’s parent for assistance might violate the client’s confidentiality and autonomy, especially if the parent is not aware of or supportive of the pregnancy. The nurse should respect the client’s right to privacy and self-determination, unless there is a risk of harm to the client or the fetus.
Choice C is wrong because referring the adolescent to a local mental health clinic might imply that the client has a mental disorder or needs psychological counseling, which could be stigmatizing and discouraging.
The nurse should assess the client’s emotional state and coping skills, and provide supportive and nonjudgmental care. The nurse can also offer referrals to other community resources, such as prenatal education, parenting classes, or social services, that might benefit the client.
Choice D is wrong because advising the adolescent to place the newborn for adoption might interfere with the client’s decision-making process and personal values.
The nurse should not impose his or her own opinions or beliefs on the client, but rather explore the client’s feelings and preferences about her pregnancy options. The nurse should provide factual information and education about adoption, abortion, or parenting, and help the client weigh the benefits and risks of each option.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Eating 1 g/kg of protein per day is the appropriate recommendation. When providing discharge teaching to a client with chronic kidney disease (CKD) who is receiving haemodialysis, the nurse should include the instruction to eat an appropriate amount of protein, which is usually recommended at a specific daily intake based on the client's weight.
Clients with CKD often have dietary restrictions, including limiting protein intake to reduce the workload on the kidneys. However, protein intake is still necessary for maintaining muscle mass and overall health. The recommended protein intake for clients with CKD undergoing haemodialysis is typically around 1 gram of protein per kilogram of body weight per day.
Choice B reason:
Drink at least 3 L of fluid daily. Clients receiving haemodialysis typically have fluid restrictions, as impaired kidney function can lead to fluid retention and electrolyte imbalances. The specific fluid allowance will be determined by the healthcare provider based on the client's individual needs, and it may be significantly less than 3 L per day.
Choice Doption
Take magnesium hydroxide for ingestion. Magnesium hydroxide is a laxative and antacid used to relieve constipation and heartburn. It is not typically prescribed for clients with chronic kidney disease, especially without proper evaluation of their kidney function and overall medical condition.
Choice Coption:
C. Consume foods high in potassium.
Clients with chronic kidney disease, especially that undergoing haemodialysis, often need to restrict potassium intake. Impaired kidney function can lead to the build-up of potassium in the blood, which can be harmful. Therefore, it is essential for clients with CKD to avoid or limit foods high in potassium.
Correct Answer is B
Explanation
The correct answer is choiceb. Waits for 2 min between suctions.
Choice A rationale:
Inserting the catheter without applying suction is correct. Suction should only be applied while withdrawing the catheter to prevent trauma to the tracheal mucosa.
Choice B rationale:
Waiting for 2 minutes between suctions is too long.The appropriate wait time is generally around 20-30 seconds to 1 minute between suction attempts to prevent hypoxia and allow the patient to recover.
Choice C rationale:
Applying suction for 15 seconds is within the recommended duration.Suctioning should not exceed 15 seconds to avoid causing hypoxia and trauma to the tracheal mucosa.
Choice D rationale:
Encouraging the client to cough during suctioning is appropriate.Coughing helps to mobilize secretions and can make suctioning more effective.
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