Nokea
A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which action by the nurse is correct?
- A. Use a magnet to remove the object.
- B. Rinse the eye thoroughly with saline.
- C. Cover both eyes with paper cups.
- D. Administer eye drops immediately.
Correct Answer: C
Rationale: Covering both eyes with paper cups is the correct action as it helps prevent consensual movement of the affected eye. Attempting to remove the object with a magnet might cause trauma, making choice A incorrect. While rinsing the eye with saline may be necessary, it should be ordered by a doctor and is not the initial action for the nurse, making choice B incorrect. Administering eye drops immediately, as in choice D, is not appropriate in this scenario and does not address the primary concern of preventing further damage by limiting eye movement.
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The difference between spirituality and religion is that spirituality is:
- A. a belief about a higher power.
- B. an individual's relationship with a higher power.
- C. organized worship.
- D. a belief in an invisible energy or ideal.
Correct Answer: B
Rationale: The correct answer is 'an individual's relationship with a higher power.' Spirituality is more about personal connection, beliefs, and experiences related to a higher power or force, whereas religion is often associated with organized practices, rituals, and doctrines within a specific faith community. Choice A is incorrect as spirituality goes beyond just believing in a higher power; it encompasses a personal connection. Choice C, 'organized worship,' is incorrect because spirituality can exist outside formal religious settings. Choice D is incorrect as it oversimplifies spirituality as merely a belief in an invisible energy or ideal, missing the relational aspect with a higher power.
Which of the following describes the stages of domestic violence in an intimate relationship?
- A. happiness, crisis, angry outburst, intervention
- B. honeymoon period, escalation of stress, outburst, reconciliation
- C. acting out and making up
- D. peace and calm, angry outburst, peace and calm, denial
Correct Answer: B
Rationale: The correct answer is B: 'honeymoon period, escalation of stress, outburst, reconciliation.' A pattern of behavior known as the cycle of abuse involves these stages. It starts with a honeymoon phase, followed by a buildup of stress, an outburst which may involve violence, and then reconciliation. This cycle is commonly observed in domestic violence situations. Choices A, C, and D do not accurately represent the stages of domestic violence in intimate relationships. Choice A mixes positive and negative elements, while choice C simplifies the complex dynamics of domestic violence. Choice D repeats 'peace and calm' inappropriately and includes 'denial,' which is not typically a stage in the cycle of abuse.
A client recently lost a child due to poisoning. The client tells the nurse, 'I don’t want to make any new friends right now.' This is an example of which of the following indicators of stress?
- A. emotional indicator
- B. spiritual indicator
- C. sociocultural indicator
- D. intellectual indicator
Correct Answer: C
Rationale: The correct answer is C, 'sociocultural indicator.' This client's reluctance to make new friends after experiencing a traumatic event like losing a child is a clear sign of sociocultural stress. Sociocultural stress can impact a person's social interactions, relationships, and cultural practices. Choices A, B, and D are incorrect. Choice A, 'emotional indicator,' would focus on emotional responses directly related to stress. Choice B, 'spiritual indicator,' refers to stress related to spiritual beliefs, practices, or values, which is not evident in this scenario. Choice D, 'intellectual indicator,' is not a recognized category of stress indicators in this context.
The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is:
- A. To lower the blood glucose level
- B. To lower the uric acid level
- C. To lower the ammonia level
- D. To lower the creatinine level
Correct Answer: C
Rationale: Lactulose is administered to the client with cirrhosis to lower ammonia levels, as it works by acidifying the colon, trapping ammonia for elimination in the stool. Choices A, B, and D are incorrect because Lactulose does not have an effect on blood glucose, uric acid, or creatinine levels. Therefore, the correct answer is to lower the ammonia level.
After the client discusses her relationship with her father, the nurse says, "Tell me whether I am understanding your relationship with your father. You feel dominated and controlled by him?"? This is an example of:
- A. verbalizing the implied.
- B. seeking consensual validation.
- C. encouraging evaluation.
- D. suggesting collaboration.
Correct Answer: B
Rationale: Seeking consensual validation is the correct answer. Consensual validation is a technique used to check one's understanding of what the client has said. It involves confirming with the client whether the nurse's interpretation aligns with the client's feelings or thoughts. This process helps build rapport, trust, and a shared understanding between the nurse and the client. Verbalizing the implied (choice A) refers to expressing the underlying or implicit meaning of a client's statement. Encouraging evaluation (choice C) involves prompting the client to assess or judge a situation. Suggesting collaboration (choice D) entails proposing working together with the client on a shared goal, which is not the primary focus in the scenario provided.