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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An appropriate question when assessing a client's self-expectations about weight loss is:
- A. What makes you think you can change your eating habits?
- B. How do you feel about losing weight?
- C. How important is it that you lose weight?
- D. What do you think is a realistic weekly weight loss for you?
Correct Answer: D
Rationale: Nurses should assist clients to evaluate themselves and make behavior changes. Listening to clients, supporting clients' strengths, assisting clients to look at themselves in totality, and encouraging clients to set attainable goals should be part of the nurse-client relationship.
Appropriate care for a client with neutropenia includes:
- A. plenty of fresh fruits and vegetables.
- B. a semi-private room.
- C. wearing a mask when out of the room.
- D. routine hand washing.
Correct Answer: C
Rationale: When a client is neutropenic, they lack the ability to fight off infection. The mask is to prevent exposure to any upper-respiratory infections.
A female prostitute enters a clinic for treatment of a sexually transmitted disease. This disease is the most prevalent STD in the United States. The nurse can anticipate that the woman has which of the following?
- A. herpes
- B. chlamydia
- C. gonorrhea
- D. syphilis
Correct Answer: B
Rationale: Epidemiological studies indicate that chlamydia is the most prevalent sexually transmitted disease in the United States.
A 57-year-old woman is recently widowed. She states, 'I will never be able to learn how to manage the finances. My husband did all of that.' Select the nurse's response that could help raise the client's self-esteem.
- A. You feel inadequate because you have never learned to balance a checkbook.
- B. You should have insisted your husband teach you about the finances.
- C. You are strong and will learn how to manage your finances after awhile.
- D. Why don't you take a class in basic finance from the local college?
Correct Answer: C
Rationale: The nurse can raise the client's self-esteem by communicating confidence the client can participate in actively finding solutions to the problem. The nurse also conveys the client is a worthwhile person by listening and accepting the client's feelings and praising the client for seeking assistance.
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.