Nokea
A battered woman seen in the emergency department requires tertiary intervention because of repeated abuse. Which nursing interventions are appropriate? Select all that apply.
- A. Report the abuse to the police.
- B. Provide medications to relieve pain and anxiety.
- C. Explore family and friends as support possibilities.
- D. Focus on the woman's strengths, endurance, and abilities.
- E. Avoid discussing the implications of pressing charges against the batterer.
- F. Discourage the woman from discussing the events leading to past and present abuse situations.
Correct Answer: A,B,C,D
Rationale: Tertiary prevention for repeated abuse focuses on overcoming physical and psychological effects and preventing future abuse. Appropriate interventions include reporting abuse to ensure safety, providing medications for pain and anxiety, exploring support options, and focusing on the woman's strengths to boost self-esteem. Avoiding discussions about pressing charges or past events is not helpful, as these help address implications and reduce guilt.
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The nurse is talking to a 67-year-old client who has just retired from the job he's had since age 17-the only job he's ever had. The nurse understands that the client is in which of Erikson's stages?
- A. intimacy versus isolation
- B. ego integrity versus despair
- C. identity versus role confusion
- D. generativity versus stagnation
Correct Answer: B
Rationale: A 67-year-old retiree is in Erikson's ego integrity versus despair stage, reflecting on life's accomplishments.
The nurse is percussing the anterior thorax and the abdomen for tones and expects to note dullness in which anatomic location? (Refer to figure.)
- A. Location 1
- B. Location 2
- C. Location 3
- D. Location 4
Correct Answer: C
Rationale: Percussion involves tapping the body with the fingertips to set the underlying structures in motion and thus produce a sound. Dullness will be noted over the liver, located in the upper right quadrant of the abdomen and beneath the lower ribs on the right side. Tympany is the most common percussion tone heard in the abdomen and is caused by the presence of gas. Resonance is the percussion tone heard between the ribs.
The nurse is preparing a community educational presentation. The topic is the leading causes of death for people ages 12-19. The nurse knows that which of the following should be presented?
- A. unintentional injuries
- B. cancer
- C. homicide
- D. suicide
Correct Answer: A
Rationale: Unintentional injuries, primarily motor vehicle accidents, are the leading cause of death for ages 12-19. Cancer (B), homicide (C), and suicide (D) are significant but rank lower.
A toddler with suspected conjunctivitis is crying and refuses to sit still during the eye examination. Which is the most appropriate statement for the nurse to make to the child?
- A. Would you like to see my flashlight?
- B. Don't be scared, the light won't hurt you.
- C. If you will sit still, the exam will be over soon.
- D. I know you are upset. We can do this exam later.
Correct Answer: A
Rationale: Engaging the toddler by offering to show the flashlight reduces fear and encourages cooperation, suitable for this developmental stage. Other options either dismiss feelings, demand compliance, or delay the necessary exam inappropriately.
The nurse reviews the pattern of a nonstress test performed on a pregnant client and interprets the finding as which result? (Refer to figure.)
- A. Reactive
- B. Abnormal
- C. Nonreactive
- D. Non-reassuring
Correct Answer: A
Rationale: A nonstress test assesses fetal well-being and evaluates the ability of the fetal heart to accelerate, often in association with fetal movement. Accelerations of the fetal heart rate are associated with adequate oxygenation, a healthy neural pathway, and the fetal heart's ability to respond to stimuli. A reactive test is described as at least two fetal heart rate accelerations, with or without fetal movement, occurring within a 20-minute period and peaking at least 15 beats/minute above the baseline and lasting 15 seconds from baseline to baseline. This recording (see figure) identifies a reactive nonstress test. The fetal heart rate acceleration peaks at least 15 beats/minute and lasts for at least 15 seconds in response to fetal movement. A nonreactive test is an abnormal or nonreassuring test. In a nonreactive test, the recording does not demonstrate the required characteristics of a reactive test within a 40-minute period.