Nokea
The nurse assesses the use of coping mechanisms by an adolescent 1 week after the client had a motor vehicle accident resulting in multiple serious injuries. Which of these characteristics are most likely to be displayed?
- A. Ambivalence, dependence, demanding
- B. Denial, projection, regression
- C. Intellectualization, rationalization, repression
- D. Identification, assimilation, withdrawal
Correct Answer: B
Rationale: Helplessness and hopelessness may contribute to regressive, dependent behavior which often occurs at any age with hospitalization. Denying or minimizing the seriousness of the illness is used to avoid facing the worst situation. Recall that denial is the initial step in the process of working through any loss.
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The nurse is caring for a client with a history of polycystic kidney disease.
- A. Which symptom is expected in a client with polycystic kidney disease?
- B. Chest pain and dyspnea.
- C. Flank pain and hematuria.
- D. Weight loss and fever.
- E. Numbness in the extremities.
Correct Answer: B
Rationale: Flank pain and hematuria are common in polycystic kidney disease due to cyst pressure and rupture. Chest pain, weight loss, and numbness are unrelated.
A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure?
- A. Playing with toys in a back yard flower garden
- B. Eating small amounts of grass while playing 'farm'
- C. Playing with cars on the pavement near burning leaves
- D. Throwing a ball to a neighborhood child who has poison ivy
Correct Answer: C
Rationale: Playing with cars on the pavement near burning leaves. Smoke from burning leaves or stems of the poison ivy plant can produce a reaction. Direct contact with the toxic oil, urushiol, is the most common cause for this dermatitis.
After the client returns to the unit, which of the following actions, if performed by the nurse, would be MOST appropriate?
- A. Position the client on her left side with her right arm protected in a sling.
- B. Position the client on her right side with her right arm elevated.
- C. Position the client in semi-Fowler's position with her right arm elevated.
- D. Position the client in the prone position with her right arm elevated.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) sling is not necessary, arm needs to be elevated (2) right arm cannot be elevated from this position (3) correct-this position will facilitate removal of fluid from venous pathways and lymphatic system through gravity; arm is elevated to enhance circulation and prevent edema (4) prone position is not appropriate
What is the most important consideration when teaching parents how to reduce risks in the home?
- A. Age and knowledge level of the parents
- B. Proximity to emergency services
- C. Number of children in the home
- D. Age of children in the home
Correct Answer: D
Rationale: Age of children in the home. Safety measures must be tailored to the developmental stage of the children.
Which of the following statements reflects Kohlberg's theory of the moral development of the preschool-age child?
- A. Obeying adults is seen as correct behavior.
- B. Showing respect for parents is seen as important.
- C. Pleasing others is viewed as good behavior.
- D. Behavior is determined by consequences.
Correct Answer: D
Rationale: In Kohlberg's preconventional stage (preschoolers), moral behavior is driven by consequences (punishment or reward). Obedience, respect, or pleasing others reflect later stages.