Nokea
A female prostitute enters a clinic for treatment of a sexually transmitted disease. This disease is the most prevalent STD in the United States. The nurse can anticipate that the woman has which of the following?
- A. herpes
- B. chlamydia
- C. gonorrhea
- D. syphilis
Correct Answer: B
Rationale: Epidemiological studies indicate that chlamydia is the most prevalent sexually transmitted disease in the United States.
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A successful resolution of the nursing diagnosis Negative Self-Concept (related to unrealistic selfexpectations) is when the client can:
- A. report a positive self-concept.
- B. identify negative thoughts.
- C. recognize positive thoughts.
- D. give one positive cue with each negative cue.
Correct Answer: A
Rationale: The problem statement is Negative Self Concept. A successful resolution of the problem is when the client can report a positive self-concept. When the nurse determines how the client perceives himself, effort should be directed to reinforce self-worth and promote a positive self-concept, including helping a client to identify areas of strength. Assisting the client to evaluate himself and make behavior changes is a nursing intervention.
A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?
- A. temperature of 102°F and a productive cough
- B. arterial blood gases (ABGs) with a PaO2 of 92 and PaCO2 of 40 mmHg
- C. trachea deviating to the right
- D. barrel-chested appearance
Correct Answer: C
Rationale: A mediastinal shift is indicative of a tension pneumothorax along with the other symptoms in the question. Because the individual was involved in an MVA, assessment is targeted at acute traumatic injuries to the lungs, heart, or chest wall rather than other conditions indicated in the other choices.
When planning care of a client who has a been diagnosed with Amphetamine Abuse, the nurse should use the knowledge that:
- A. amphetamines increase energy by increasing dopamine levels at neural synapses.
- B. amphetamines have a low risk of tolerance or addiction.
- C. amphetamines produce a 10-20-second rush followed by a 2-4-hour high.
- D. addiction to barbiturates and amphetamines is rare because they have opposite effects.
Correct Answer: A
Rationale: Amphetamines cause the release of norepinephrine and dopamine from storage vesicles into the synapse, increasing stimulation. Tolerance and withdrawal patterns are well-documented, and prolonged use can lead to psychosis.
Two staff nurses were considered for promotion to head nurse. The promotion is announced via a memo on the unit bulletin board. When the nurse who was not promoted first read the memo and learned that the other nurse had received the promotion, she left the room in tears. This behavior is an example of:
- A. Conversion
- B. Regression
- C. Introjection
- D. Rationalization
Correct Answer: B
Rationale: Crying reflects regression, a return to a less mature emotional response to disappointment. Conversion involves physical symptoms, introjection is identification with another, and rationalization is justifying feelings.
Which of the following statements is correct regarding rape?
- A. Most rapes are reported
- B. Legally, a woman can be raped by her spouse
- C. Prosecution and conviction for rape is easy
- D. The most common location of rape is the victim's own home
Correct Answer: B
Rationale: Spousal rape is legally recognized as non-consensual sexual intercourse within marriage. Most rapes are underreported, prosecution is challenging, and rapes occur in various locations, not predominantly at home.