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: Counseling by a rape crisis nurse specialist is a form of crisis intervention, providing immediate support to address the trauma. It is not merely assessment, empathy, or intrusion. Coordinated Care
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Steatorrhea:
Steatorrhea:
- A. Greasy stools
- B. Loose, frequent bowel movement
- C. Constipation
- D. Melena
Correct Answer: A
Rationale: Steatorrhea involves greasy, fatty stools due to fat malabsorption.
Steam inhalation is prescribed for a client. Which of the following safety precautions should the nurse include in the client's instructions?
- A. Use distilled water in the humidifier.
- B. Keep the humidifier filled to the top with water.
- C. Turn the humidifier off when not in use.
- D. Clean the humidifier every 2 weeks.
Correct Answer: C
Rationale: Turning off the humidifier when not in use prevents electrical hazards and bacterial growth. Distilled water is ideal but not critical, overfilling is unnecessary, and cleaning frequency depends on use.
A client's vision is to be evaluated using the Ishihara exam. The nurse recognizes that the client will be checked for:
- A. Macular degeneration
- B. Astigmatism
- C. Color blindness
- D. Glaucoma
Correct Answer: C
Rationale: The Ishihara exam tests for color blindness by assessing color perception. It does not evaluate macular degeneration, astigmatism, or glaucoma.
The client states, 'My discharge plan leaves me with a lot to do. I don't think I can do it. I'm never good at doing things.' The nurse knows the client lacks:
- A. maturation.
- B. organization.
- C. readiness to learn.
- D. self-efficacy.
Correct Answer: D
Rationale: Expressing doubt in ability to manage the discharge plan indicates low self-efficacy, a belief in one's capacity to execute tasks.
An adult is to have a paracentesis performed today. What should the nurse do before the procedure?
- A. Encourage the client to drink large amounts of fluids
- B. Ask the client to empty her bladder just before the test
- C. Keep the client NPO until after the procedure
- D. Premedicate the client as ordered
Correct Answer: B
Rationale: Emptying the bladder before paracentesis prevents accidental puncture of the bladder during needle insertion into the abdominal cavity. Fluid intake, NPO status, or premedication are not immediate pre-procedure priorities.