Nokea
A client is 36 hours post-op a TKR surgery, 270 cc's of sero-sanguinous accumulates in the surgical drains. What action should the nurse take?
- A. Notify the doctor
- B. Empty the drain
- C. Do nothing
- D. Remove the drain
Correct Answer: A
Rationale: The physician should be notified if excessive drainage is noted from the surgical site.
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Which intervention should the nurse take first to assist a woman who states that she feels incompetent as the mother of a teenage daughter?
- A. Recommend that she discipline her daughter more strictly and consistently.
- B. Make a list of things her husband can do to help her improve.
- C. Assist the mother to identify what she believes is preventing her success and what she can do to improve.
- D. Explore with the mother what the daughter can do to improve her behavior.
Correct Answer: C
Rationale: The intervention priority with a mother who feels incompetent to parent a teenage daughter is to assist the mother to identify what she feels her crisis events are and to help her develop better coping skills and improve her mothering skills. With a teenager, the growth and development parameters have to be concentrated on self as well as acquiring an added event. Choices 1, 2, and 4 do not directly address the mother's feelings of inadequacy.
Which of the following lab values would indicate symptomatic AIDS in the medical chart? (T4 cell count per deciliter)
- A. Greater than 1000 cells per deciliter
- B. Less than 500 cells per deciliter
- C. Greater than 2000 cells per deciliter
- D. Less than 200 cells per deciliter
Correct Answer: D
Rationale: A T4 cell count less than 200 cells per deciliter indicates symptomatic AIDS, as it reflects severe immunosuppression.
A batterer is usually someone who:
- A. grew up in a loving, secure home.
- B. was an only child.
- C. was physically or psychologically abused.
- D. admits he has a problem with anger.
Correct Answer: C
Rationale: Many batterers report having been abused as children.
In alcoholics with anemia:
- A. pernicious anemia is more common than folic acid deficiency.
- B. iron deficiency and folic acid deficiency can coexist.
- C. the alcohol interferes with iron absorption.
- D. oral vitamin replacement is contraindicated.
Correct Answer: B
Rationale: The ingestion of nonfood substances (alcohol) can lead to a clinical iron deficiency and might actually be the first sign of a problem. The client might substitute alcohol for a nutrition program that fosters a positive health habit.
The most effective nursing strategy to assist a client in recognizing and using personal strength includes:
- A. encouraging the client's self-identification of strengths
- B. promoting the client's active external thinking
- C. listening to the client and providing advice as needed
- D. assisting the client in maintaining an external locus of control
Correct Answer: A
Rationale: Encouraging self-identification of strengths empowers the client to recognize their capabilities, fostering confidence and resilience. External thinking or locus of control may disempower, and advice-giving is less effective than self-discovery.