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 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.
A successful resolution of the nursing diagnosis Negative Self-Concept (related to unrealistic selfexpectations) is when the client can:
- A. report a positive self-concept.
- B. identify negative thoughts.
- C. recognize positive thoughts.
- D. give one positive cue with each negative cue.
Correct Answer: A
Rationale: The problem statement is Negative Self Concept. A successful resolution of the problem is when the client can report a positive self-concept. When the nurse determines how the client perceives himself, effort should be directed to reinforce self-worth and promote a positive self-concept, including helping a client to identify areas of strength. Assisting the client to evaluate himself and make behavior changes is a nursing intervention.
A couple from the Philippines living in the United States is expecting their first child. In providing culturally competent care, the nurse must first:
- A. review their own cultural beliefs and biases
- B. respectfully request that the couple utilize only medically approved health care providers
- C. realize that the clients have to learn their new country's accepted medical practices
- D. study family dynamics to understand the male and female gender roles in the clients' culture
Correct Answer: A
Rationale: The nurse must first examine their own cultural biases to avoid imposing personal beliefs, ensuring culturally sensitive care. The other options assume or impose external standards without prioritizing self-awareness.
A nurse is assessing a patient's breath sounds. The patient has had a pneumonectomy to the right lung performed 48 hours ago. Which of the following conditions most likely exists?
- A. Decreased breath sound volume
- B. Elevated tidal volume
- C. Elevated respiratory capacity
- D. Wheezing
Correct Answer: A
Rationale: Breath sounds would be softer due to the removal of the right lung, reducing the area available for air exchange.
A 24 year-old man has been admitted to the hospital due to work-related back injury. The patient's wife would like to see the patient's chart. The nurse should:
- A. Provide the chart to the patient's wife following verbal approval by the patient.
- B. Provide the chart to the patient's wife after consulting with the patient's physician.
- C. Get written approval from the patient prior to providing the wife with chart information and call the MD about the patient's request.
- D. Tell the patient's wife, a copy of the patient's medical record is on-file with medical records.
Correct Answer: C
Rationale: Some facilities require the physician to be notified about a patient's request and written permission from the husband is required for the wife to view the chart.