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A 12-year-old boy is admitted due to depression and post-trauma response. Child Protective Services reports that the boy's father is now in jail for molesting him from ages 6 to 9. Given the typical reactions of incest victims, the nurse should assess the child for which behavior? Select all that apply.
- A. Sexualized play.
- B. Aggression.
- C. Isolation at home.
- D. Running away.
- E. Truancy.
Correct Answer: A, B, C, D, E
Rationale: Incest victims may exhibit sexualized play, aggression, isolation, running away, and truancy as coping mechanisms or trauma responses.
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The client scheduled for a transurethral resection prostatectomy (TURP) asks the nurse to explain how the prostate is going to be removed. The nurse should tell the client that the prostate will be removed through which pathway?
- A. The urethra
- B. A lower abdominal incision
- C. An upper abdominal incision
- D. An incision made in the perineal area
Correct Answer: A
Rationale: A TURP is done through the urethra. An instrument called a resectoscope is used to remove the tissue using high-frequency current. A lower abdominal incision is used for suprapubic or retropubic prostatectomy. An upper abdominal incision is not used. An incision between the scrotum and anus is made when a perineal prostatectomy is performed.
A nurse is assessing a client who has a potential diagnosis of pancreatitis. Which risk factors predispose the client to pancreatitis? Select all that apply.
- A. Excessive alcohol use.
- B. Gallstones.
- C. Abdominal trauma.
- D. Hypertension.
- E. Hyperlipidemia with excessive triglycerides.
- F. Hypothyroidism.
Correct Answer: A,B,C,E
Rationale: Excessive alcohol use, gallstones, abdominal trauma, and hyperlipidemia with high triglycerides are established risk factors for pancreatitis, as they can disrupt塌 or obstruct pancreatic ducts or cause inflammation.
The nurse monitors the serum electrolyte levels of a client who is taking digoxin (Lanoxin). Which of the following electrolyte imbalances is a common cause of digoxin toxicity?
- A. Hyponatremia.
- B. Hypomagnesemia.
- C. Hypocalcemia.
- D. Hypokalemia.
Correct Answer: D
Rationale: Hypokalemia enhances digoxin's effect on the heart, increasing toxicity risk by altering cardiac membrane potential.
A client tells the nurse, 'Everybody smiles at me because they know that I was chosen by God for this mission.' The nurse interprets this statement as which of the following?
- A. Idea of reference.
- B. Thought insertion.
- C. Visual hallucination.
- D. Neologism.
Correct Answer: A
Rationale: The statement reflects an idea of reference, where the client believes others' actions (smiling) are related to their special mission, a common delusion in psychiatric conditions.
What is the primary goal of multidisciplinary case conferences?
- A. To fulfill the nurse's role in terms of collaboration
- B. To plan and provide for optimal client outcomes
- C. To solve complex multidisciplinary patient care problems
- D. To provide educational experiences for experienced nurses
Correct Answer: B
Rationale: The primary goal of multidisciplinary case conferences is to plan and provide for optimal client outcomes by bringing together various professionals to coordinate care and address the client's needs holistically.