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A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the 'tension-building phase,' the nurse might expect the client to describe which of the following?
- A. Promises of gifts that her husband made to her
- B. Acute battering of the client, characterized by his volatile discharge of tension
- C. Minor battering incidents, such as the throwing of food or dishes at her
- D. A period of tenderness between the couple
Correct Answer: C
Rationale: This description is characteristic of the 'tension-building' phase prior to the volatile discharge of tension found in the battering phase.
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A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:
- A. Bleeding, bruising, and hemorrhage
- B. Increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase
- C. Pain, pallor, pulselessness, paresthesia, and paralysis
- D. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus
Correct Answer: C
Rationale: Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five 'P's': pain, pallor, pulselessness, paresthesia, and paralysis. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia.
A client with a head injury asks why he cannot have something for his headache. The nurse's response is based on the understanding that analgesics could:
- A. Counteract the effects of antibiotics
- B. Elevate the blood pressure
- C. Mask symptoms of increasing intracranial pressure
- D. Stimulate the central nervous system
Correct Answer: C
Rationale: Analgesic medication does not counteract the effects of antibiotics. Analgesic medication may lower blood pressure elevated due to anxiety. Analgesic medication, especially CNS depressants, is not given if there is danger of increasing ICP, because neurological changes may not be apparent. Also, further depression of the CNS is contraindicated. Analgesics do not stimulate the CNS.
The doctor has ordered antithrombotic stockings to be applied to the legs of a client with peripheral vascular disease. The nurse knows antithrombotic stockings should be applied:
- A. Before the client arises in the morning
- B. With the client in a standing position
- C. After the client has bathed and applied lotion to the legs
- D. Before the client retires in the evening
Correct Answer: A
Rationale: Antithrombotic stockings should be applied before the client arises in the morning when edema is minimal, ensuring proper fit and maximum compression to promote venous return. Applying them later or after lotion can reduce effectiveness or cause skin irritation.
The nurse is caring for a client with a history of schizophrenia. The nurse should expect the client to have:
- A. Hallucinations
- B. Memory loss
- C. Tremors
- D. Joint pain
Correct Answer: A
Rationale: Schizophrenia is characterized by hallucinations, delusions, and disorganized thinking, with hallucinations being a common symptom.
Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?
- A. Brushing the teeth
- B. Drinking a glass of juice
- C. Holding a cup of coffee
- D. Brushing the hair
Correct Answer: C
Rationale: Holding a warm cup of coffee can reduce morning stiffness in rheumatoid arthritis by providing warmth and encouraging gentle hand movement. The other activities do not specifically alleviate joint stiffness.