Nokea
A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:
- A. assessment.
- B. crisis intervention.
- C. empathetic concern.
- D. unwarranted intrusion.
Correct Answer: B
Rationale: Choice 2 is part of the Crisis Intervention Model. Counseling by a nurse specialist at the time of a stressful event (rape) can strengthen the client's coping. A nurse specialist in rape crisis intervention is educationally prepared in counseling and crisis intervention specific to rape victims.
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A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as:
- A. plantar fasciitis.
- B. hallux valgus.
- C. hammertoe.
- D. Morton's neuroma.
Correct Answer: D
Rationale: Morton's neuroma is a small mass or tumor in a digital nerve of the foot. Hallux valgus is referred to in lay terms as a bunion. Hammertoe is where one toe is cocked up over another toe. Plantar fasciitis is an inflammation of, or pain in, the arch of the foot.
The nurse explains to a client who underwent gastric resection that which of the following meals is most likely to cause rapid emptying of the stomach?
- A. a high-protein meal
- B. a high-fat meal
- C. a large meal regardless of nutrient content
- D. a high-carbohydrate meal
Correct Answer: D
Rationale: Meals that are high in carbohydrates promote rapid gastric emptying. The other options are associated with decreased emptying time.
A standard walker is used when clients:
- A. have poor balance, cannot stand up, have weak arms, and have good hand strength.
- B. have poor balance, have a broken leg, or have experienced amputation.
- C. have poor balance, have cardiac problems, or cannot use crutches or a cane.
- D. have poor balance, have an autoimmune disease, or have weak arms.
Correct Answer: C
Rationale: A walker is used for clients who have balance problems, cardiac problems, or cannot use crutches or a cane. The client needs to bear partial weight and have strength in her wrists and arms. The client uses her upper body to propel the walker forward.
Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?
- A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m.
- B. taking a cool shower and drinking a hot cup of tea
- C. watching TV nightly until midnight
- D. getting a back rub and drinking a glass of warm milk
Correct Answer: D
Rationale: A back rub and warm milk promote relaxation and sleep. Vigorous exercise, cool showers, hot tea, and late TV watching are stimulating and disrupt sleep.
The client with a new colostomy asks how to deal with gas coming from the stoma. To respond to the client's concern, the nurse should ask the client to take which action? Select all that apply.
- A. Describe the dietary intake, including types of foods.
- B. Include cruciferous vegetables in the diet daily.
- C. Decrease fluid intake to 1200 mL per 24 hours.
- D. Prick the colostomy stoma pouch with a pin.
- E. Limit intake of gas-producing carbonated sodas.
- F. In the bathroom, open the pouch clamp to release gas.
Correct Answer: A,E,F
Rationale: A: Assessing diet identifies gas-producing foods. E: Limiting carbonated drinks reduces gas. F: Releasing gas in a bathroom controls odor. B: Cruciferous vegetables increase gas. C: Reduced fluid risks dehydration. D: Pricking the pouch causes leaks and odor.