Nokea
A blended family has six children, ages 2, 4, 4, 5, 7, and 10. During a visit to the home, the nurse notices that the 7-year-old seems quiet and withdrawn, whereas the other children are playing loudly in the garage. Which of the following conclusions can the nurse make from this observation?
- A. This child has most likely been abused.
- B. This child is one of multiple children closely spaced in age.
- C. This family suffers from low self-esteem.
- D. This family provides harsh punishment for their children.
Correct Answer: B
Rationale: Risks in blended families include multiple closely spaced children, which can make it difficult for parents to attend to each child’s individual needs.
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A nurse is caring for a woman during the fourth stage of labor. Which of the following best describes an action the nurse would take during this stage?
- A. Providing constant reinforcement and education about the labor process and assisting the woman with pushing
- B. Explaining unusual interventions such as the use of a fetal heart monitor
- C. Assisting with labor discomfort by modeling breathing
- D. Teaching the new mother positioning of the infant to assist with breast-feeding
Correct Answer: D
Rationale: In the fourth stage of labor, the nurse supports breastfeeding and assists with positioning the infant.
A nurse is investigating an outbreak of a food-borne illness occurring at a local school. Which of the following would contribute to a chemical contamination resulting in food-borne illness?
- A. Unintended allergen added to food
- B. Bacteria on the countertops
- C. Pesticide on the fresh fruit
- D. Metal shavings in the food from a dull can opener
Correct Answer: C
Rationale: Pesticides on fresh fruit are a source of chemical contamination.
Respecting Spirituality
- A. Changing the position of the bed in a Muslim client’s room so that it faces east
- B. Contacting the chaplain to assess spiritual needs
- C. Saying a silent prayer with a client at their request
- D. Praying out loud in a dying client's room
Correct Answer: C
Rationale: Praying quietly with respect for the client's beliefs is more appropriate than imposing religious actions.
A nurse administers the T-ACE test to a pregnant woman. The woman’s responses result in a score of 3. This score indicates that the woman:
- A. requires interventions for problem drinking.
- B. lacks evidence of problem drinking.
- C. requires interventions for sexually transmitted disease risks.
- D. lacks evidence of sexually transmitted disease risks.
Correct Answer: A
Rationale: A score of 2 or higher on the T-ACE indicates the need for intervention for problem drinking in pregnant women.
An emergency department provides care for all individuals regardless of circumstances and ability to pay. This is an example of:
- A. Ethic of justice
- B. Ethic of care
- C. Applied ethics
- D. Metaethics
Correct Answer: A
Rationale: The ethic of justice is impartial and nondiscriminatory, ensuring care is provided to everyone equally.