Nokea
A 13-year-old male was kidnapped and held for ransom by two criminals. His parents asked to have him admitted to the adolescent psychiatric unit. He is sleep-deprived, filthy, alternating between sobbing and making threats to kill his captors, and then asks to go to sleep. What is the best initial plan for this client?
- A. Encourage him to talk with the Federal Bureau of Investigation (FBI) about the crime details.
- B. Develop trust and allow him to talk about his memories and feelings.
- C. Help him and his parents prepare for the future trial.
- D. Discourage him from making threats toward his captors.
Correct Answer: B
Rationale: Building trust and allowing the client to express feelings addresses immediate emotional needs and trauma, prioritizing mental health support.
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You are fully aware of the fact that some risk factors are correctable or modifiable and other risk factors are innate and not modifiable. Which of the following risk factors are most likely to be correctable?
- A. Genetic predisposition
- B. Lifestyle choices
- C. High risk behaviors
- D. An external locus of control
Correct Answer: B,C
Rationale: Lifestyle choices (e.g., diet, exercise) and high-risk behaviors (e.g., smoking, substance abuse) are modifiable risk factors that can be addressed through education and behavior change. Genetic predisposition and an external locus of control are less easily modified.
Which of the following suggestions should the nurse give to an adolescent football player with Osgood-Schlatter disease of the left knee?
- A. Apply ice on the knee after playing.
- B. Use crutches until healing has occurred.
- C. Stop playing until healing has occurred.
- D. Make an appointment with a physical therapist.
Correct Answer: A
Rationale: Applying ice after activity reduces inflammation and pain in Osgood-Schlatter disease.
A client has polycystic kidney disease. The client asks the nurse, 'How did I get these fluid-filled bubbles on my kidneys? I have not had any X-ray type tests.' How should the nurse respond to help the client understand risk factors for this disease process?
- A. Second-hand smoke puts you at greater risk for developing cysts.'
- B. Exposure to dyes used to color fruits and vegetables increases the risk of polycystic kidney disease.'
- C. There is a higher incidence of polycystic kidney disease among blood relatives.'
- D. Drinking alcohol daily allows the kidneys to develop cysts.'
Correct Answer: C
Rationale: Polycystic kidney disease is primarily genetic, with a higher incidence among blood relatives due to autosomal dominant or recessive inheritance patterns.
A client has a prescription to begin short-term therapy with enoxaparin. The nurse explains to the client that this medication is being prescribed for which action?
- A. Dissolve urinary calculi
- B. Relieve migraine headaches
- C. Stop progression of multiple sclerosis
- D. Reduce the risk of deep vein thrombosis
Correct Answer: D
Rationale: Enoxaparin is an anticoagulant that is administered to prevent deep vein thrombosis and thromboembolism in selected clients at risk. It is not used to treat urinary calculi, migraine headaches, or multiple sclerosis.
A client with angina shows the nurse her nitroglycerin (Nitrostat) that she carries in a plastic bag in her pocket. The nurse instructs the client that nitroglycerin should be kept in:
- A. The refrigerator.
- B. A cool, moist place.
- C. A dark container to shield from light.
- D. A plastic bag where it is readily available.
Correct Answer: C
Rationale: Nitroglycerin is sensitive to light and heat, which can degrade its potency. Storing it in a dark container protects it from light exposure, ensuring effectiveness.