Nokea
A football player is well paid for his superior athletic ability. Described by his friends as quiet and brooding, on the field he is known for his overly aggressive plays. The client's behavior is an example of:
- A. Displacement
- B. Conversion
- C. Sublimation
- D. Repression
Correct Answer: C
Rationale: Sublimation involves channeling emotions (e.g., aggression) into socially acceptable outlets, like sports. Displacement, conversion, and repression do not fit.
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A home health nurse is managing care for an adolescent client with cystic fibrosis. Which of the following potential complications should the nurse consider when developing a nursing care plan? Select all that apply.
- A. Chronic hypoxemia
- B. Diabetes insipidus
- C. Frequent respiratory infections
- D. Obesity
- E. Vitamin deficiencies
Correct Answer: A,C,E
Rationale: Cystic fibrosis causes chronic hypoxemia , frequent infections , and vitamin deficiencies due to malabsorption. Diabetes insipidus is unrelated, and obesity is unlikely due to high metabolic demand.
The nurse is caring for a client who is experiencing the cardiac rhythm shown in the ECG strip below. The nurse should recognize that the client is experiencing
- A. atrial fibrillation
- B. ventricular fibrillation
- C. sinus bradycardia
- D. normal sinus rhythm
Correct Answer: B
Rationale: Ventricular fibrillation is a life-threatening arrhythmia requiring immediate intervention. Atrial fibrillation , sinus bradycardia , and normal rhythm are less urgent.
The nurse is talking with the parent of a 5-year-old client about managing recurrent nosebleeds at home. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
- A. Apply direct pressure by pinching your child's nostrils together for 5-15 minutes.
- B. Take your child to the emergency department as soon as possible.
- C. Tell your child to lie down and turn your child on the left side.
- D. Provide reassurance to keep your child calm and quiet.
- E. Place a cold cloth over the bridge of your child's nose.
Correct Answer: A,D,E
Rationale: Pressure , reassurance , and cold cloth control bleeding and anxiety. ED visits are unnecessary for recurrent nosebleeds, and lying down risks aspiration.
A Spanish-speaking client is admitted for a small bowel obstruction. The surgeon explains to the client's child, who speaks both Spanish and English, that an exploratory laparotomy is needed to determine the cause of the obstruction and that possible causes include intestinal adhesions and ovarian or colon cancer. The surgeon asks the child to translate this information for the client and assist with translating the consent form. Which action by the nurse would be most appropriate?
- A. Act as a witness for the informed consent process
- B. Reinforce information about what the client can expect
- C. Report the surgeon to the ethics board for using an inappropriate consent process
- D. Talk to the surgeon privately about using a trained Spanish-language medical interpreter
Correct Answer: D
Rationale: Using a trained interpreter ensures accurate, unbiased communication. Witnessing or reinforcing perpetuates the error, and reporting is premature.
After the shift report in a labor and delivery unit which of these clients would the nurse check first?
- A. A middle aged woman with asthma and Type 1 diabetes mellitus has a BP of 150/94
- B. A middle aged woman with a history of two prior vaginal term births is 2 cm dilated
- C. A young woman who is a grand multipara has cervical dilation of 4 cm and is 50% effaced
- D. An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum
Correct Answer: D
Rationale: This client has an actual complication. The others present with findings of potential complications. The adolescent’s symptoms suggest a serious condition, possibly pulmonary edema or fetal demise, requiring immediate assessment.