Nokea
A client tells the nurse that his wife's nagging really gets on his nerves. He asks the nurse to talk with her about her nagging during their family session tomorrow afternoon. Which of the following responses is the most therapeutic for the client?
- A. "Tell me more specifically about her complaints."?
- B. "Can you think of reasons why she might nag you so much?"?
- C. "I'll help you think about how to bring this up yourself tomorrow afternoon."?
- D. "Why do you want me to initiate this in tomorrow's session rather than you?"?
Correct Answer: C
Rationale: The most therapeutic response is to empower the client to address the issue himself. By offering assistance in thinking about how to bring up the topic during the family session, the nurse is promoting the client's autonomy and communication skills. This response encourages the client to take an active role in resolving the situation. Choices A and B focus on the wife's behavior, which is not the immediate concern during this interaction. Choice D challenges the client's request and shifts the responsibility back to the client, potentially hindering progress and discouraging open communication.
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A 10-month-old child is brought to the Emergency Department because he is difficult to awaken. The nurse notes bruises on both upper arms. These findings are most consistent with:
- A. wearing clothing that is too small for the child.
- B. the child being shaken.
- C. falling while learning to walk.
- D. parents trying to awaken the child.
Correct Answer: B
Rationale: The correct answer is 'the child being shaken.' In cases of suspected child abuse, bruises on both upper arms can be indicative of a child being shaken, as children who are shaken are frequently grasped by both upper arms. The presentation of a 10-month-old child being difficult to awaken, along with bruises on the upper arms, raises concern for inflicted injury. Symptoms of brain injury associated with shaking include a decreased level of consciousness. Choices A, C, and D are less likely in this scenario as they do not align with the concerning signs of suspected abuse indicated by the bruises and the child's altered level of consciousness.
The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?
- A. "How did you get those bruises?"?
- B. "Did someone grab you by your arms?"?
- C. "Do you fall often?"?
- D. "What did you bump against?"?
Correct Answer: B
Rationale: The correct answer is asking, "Did someone grab you by your arms?"? This question is direct and addresses the possibility of abuse, which is crucial when dealing with suspected abuse cases. It is important to ask direct questions in a sensitive and non-accusatory manner to gather information. Choice A is too general and may not prompt a disclosure of abuse. Choice C assumes falling as the cause without addressing abuse directly. Choice D is vague and does not specifically inquire about potential abuse, making it less effective in identifying abuse cases compared to the correct choice.
In the United States, several definitions of death are currently being used. The definition that uses apnea testing and pupillary responses to light is termed:
- A. whole brain death.
- B. heart-lung death.
- C. circulatory death.
- D. higher brain death.
Correct Answer: A
Rationale: The correct answer is 'whole brain death.' Most protocols for determining whole brain death require two separate clinical examinations, including the induction of painful stimuli, pupillary responses to light, oculovestibular testing, and apnea testing. This comprehensive approach ensures that all functions of the brain, including the brainstem, are evaluated to confirm the absence of brain function. Choices B and D are incorrect as they do not reflect the specific tests required for determining whole brain death. Choice C, 'circulatory death,' does not involve the evaluation of brain function and is not a current definition of death in the United States.
When assessing a client with glaucoma, a nurse expects which of the following findings?
- A. Complaints of double vision
- B. Complaints of halos around lights
- C. Intraocular pressure of 15 mm Hg
- D. Soft globe on palpation
Correct Answer: B
Rationale: When assessing a client with glaucoma, a common finding is complaints of halos around lights. Other symptoms of glaucoma include loss of peripheral vision or blind spots, reddened sclera, firm globe, decreased accommodation, and occasional eye pain. Glaucoma may be asymptomatic until permanent damage to the optic nerve and retina occurs. Double vision is not a typical symptom of glaucoma. In terms of intraocular pressure, normal levels range from 10 to 21 mm Hg, making an intraocular pressure of 15 mm Hg within the normal range. A soft globe on palpation is not a typical finding in glaucoma.
Who may legally give informed consent?
- A. an 86-year-old male with advanced Alzheimer's disease
- B. a 14-year-old girl needing an appendectomy who is not an emancipated minor
- C. a 14-year-old girl needing an appendectomy who is not an emancipated minor
- D. a 6-month-old baby needing bowel surgery
Correct Answer: C
Rationale: The correct answer is a 14-year-old girl needing an appendectomy who is not an emancipated minor. Informed consent can be given by individuals who are competent and not minors. Minors are generally unable to provide informed consent unless they are emancipated. Choice A is incorrect because an 86-year-old male with advanced Alzheimer's disease is considered incompetent to make decisions. Choice D is incorrect because a 6-month-old baby is unable to provide consent. Emancipated minors are an exception to the minor rule, as they can provide consent for their own treatment.