Nokea
A 10-month-old child is brought to the Emergency Department because he is difficult to awaken. The nurse notes bruises on both upper arms. These findings are most consistent with:
- A. wearing clothing that is too small for the child.
- B. the child being shaken.
- C. falling while learning to walk.
- D. parents trying to awaken the child.
Correct Answer: B
Rationale: Children who are shaken are frequently grasped by both upper arms. Symptoms of brain injury associated with shaking include decreased level of consciousness.
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A nurse is caring for a client with an elevated urine osmolarity. The nurse should assess the client for:
- A. fluid volume excess.
- B. hyperkalemia.
- C. hypercalcemia.
- D. fluid volume deficit.
Correct Answer: D
Rationale: For a client with an elevated urine osmolarity, the nurse should assess the client for fluid volume deficit.
Nursing considerations when caring for African-American clients include that:
- A. families are generally distant and unsupportive
- B. special hair, skin, and nail care might be required
- C. fad diets are a cultural norm
- D. clients are generally future-oriented
Correct Answer: B
Rationale: African-American clients may require specific hair, skin, and nail care due to unique characteristics like tightly coiled hair or higher risk of keloid scarring. The other options are stereotypes or incorrect: families are often supportive, fad diets are not a cultural norm, and future orientation is not a defining trait.
When planning care of a client who has a been diagnosed with Amphetamine Abuse, the nurse should use the knowledge that:
- A. amphetamines increase energy by increasing dopamine levels at neural synapses.
- B. amphetamines have a low risk of tolerance or addiction.
- C. amphetamines produce a 10-20-second rush followed by a 2-4-hour high.
- D. addiction to barbiturates and amphetamines is rare because they have opposite effects.
Correct Answer: A
Rationale: Amphetamines cause the release of norepinephrine and dopamine from storage vesicles into the synapse, increasing stimulation. Tolerance and withdrawal patterns are well-documented, and prolonged use can lead to psychosis.
The nurse is caring for a dying client who has persistently requested that the nurse 'help her to die and be in peace.' According to the Code of Ethics for Nurses, the nurse should:
- A. Ask the client whether she has signed the advance directives document.
- B. Tell the client that he or she will ask another nurse to care for her.
- C. Instruct the client that only a physician can legally assist a suicide.
- D. Try to make the client as comfortable as possible, but refuse to assist in death.
Correct Answer: D
Rationale: Try to make the client as comfortable as possible but refuse to assist in death. One of the competencies necessary for nurses to have in giving high quality care to clients/families during the end of life care is: apply legal and ethical principles in the analysis of complex issues and end-of-life care, recognizing the influence of personal values, profession codes, and client preferences.
James returns home from school angry and upset because his teacher gave him a low grade on an assignment. After returning home from school, he kicks the dog. This coping mechanism is known as:
- A. denial.
- B. suppression.
- C. displacement.
- D. fantasy.
Correct Answer: C
Rationale: Displacement is the transference of anger to another. Anger is displaced on the dog as a convenient object.