Nokea
A high school nurse observes a 14 year-old female rubbing her scalp excessively in the gym. The most appropriate course of action for the nurse to do is:
- A. Request a private evaluation of the female's scalp from her parents.
- B. Contact the female's parents about the observations.
- C. Observe the hairline and scalp for possible signs of lice.
- D. Contact the student's physician.
Correct Answer: C
Rationale: Observation of the student's hair is the next step.
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Which statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel (UAP) to help a client ambulate for the first time after a colon resection?
- A. Have the client sit on the side of the bed before helping the client to walk.
- B. If the client is dizzy ask the client to take some slow, deep breaths.
- C. Help the client to walk in the room as often as the client wishes.
- D. When you help the client to walk, ask if any pain occurs.
Correct Answer: A
Rationale: This statement gives clear directions to the UAP about the task and is most closely associated with the information provided in the stem that this is the client's first time out of bed after surgery.
Which characteristic is most likely to be present in persons who abuse others?
- A. Financial security
- B. Positive self-image
- C. Substance abuse
- D. Physical illness
Correct Answer: C
Rationale: Substance abuse is strongly associated with abusive behavior due to impaired judgment and aggression. Financial security, self-image, or illness are less predictive.
A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to
- A. Convince the client that the hospital staff is trying to help
- B. Help the client to enter into group recreational activities
- C. Provide interactions to help the client learn to trust staff
- D. Arrange the environment to limit the client's contact with other clients
Correct Answer: C
Rationale: Provide interactions to help the client learn to trust staff. Establishing trust helps clients feel safer and facilitates a therapeutic alliance between staff and client.
The nurse is caring for a client with a history of multiple sclerosis.
- A. Which symptom is expected in a client with multiple sclerosis?
- B. Chest pain and shortness of breath.
- C. Muscle weakness and spasticity.
- D. Weight gain and edema.
- E. Persistent headaches.
Correct Answer: B
Rationale: Muscle weakness and spasticity are common in multiple sclerosis due to demyelination of nerve fibers. Chest pain, edema, and headaches are not typical symptoms.
A patient is scheduled for electro-convulsive therapy treatment scheduled in the morning. What must the evening nurse do to provide the client ECT treatment possible?
- A. Patient signs an informed consent form
- B. Patient is given morning medications
- C. Patient gets a good night's sleep
- D. Patient has a good breakfast
Correct Answer: A
Rationale: An informed consent is required prior to surgery.