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.
What is the reason for a contract between nurse and client?
- A. Contracts state the roles the participants take.
- B. Contracts are indicative of the feeling tone established between participants.
- C. Contracts are binding and prevent either party from ending the relationship prematurely.
- D. Contracts spell out the participation and responsibilities of both parties.
Correct Answer: D
Rationale: A contract emphasizes that the nurse works with the client, rather than doing something for the client. Working with suggests that each party is expected to participate and share responsibility for outcomes. Contracts do not, however, stipulate roles or feeling tone, nor is premature termination expressly forbidden.
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.
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.
A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?
- A. temperature of 102°F and a productive cough
- B. arterial blood gases (ABGs) with a PaO2 of 92 and PaCO2 of 40 mmHg
- C. trachea deviating to the right
- D. barrel-chested appearance
Correct Answer: C
Rationale: A mediastinal shift is indicative of a tension pneumothorax along with the other symptoms in the question. Because the individual was involved in an MVA, assessment is targeted at acute traumatic injuries to the lungs, heart, or chest wall rather than other conditions indicated in the other choices.