Nokea
A husband and wife and their two children, age 9 and age 5, are requesting family therapy. Which of the following strategies is most therapeutic for the nurse to use during the initial interaction with a family?
- A. Always allow the most vocal person to state the problem first.
- B. Encourage the mother to speak for the children.
- C. Interpret immediately what seems to be going on within the family.
- D. Allow family members to assume the seats as they choose.
Correct Answer: D
Rationale: Allowing family members to choose their own seats will assist the nurse in assessing the family system and in determining who feels closer to whom.
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A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of:
- A. Loss of ability to speak and communicate effectively
- B. Aspiration and weight loss
- C. Secondary infection resulting from poor oral hygiene
- D. Drooling
Correct Answer: B
Rationale: Loss of ability to speak is not dysphasia. Although the client may have difficulty communicating, alternative measures can be developed to enhance communication. This goal, while important, is of a lesser priority. Dysphasia is difficulty swallowing, which could result in aspiration of food and inability to eat, causing weight loss. A secondary infection could result from poor oral hygiene, which could enhance the client's inability to eat, but this goal is of a lesser priority. Drooling normally occurs in clients with amyotrophic lateral sclerosis and may require suctioning. Drooling, while aggravating for the client, does not pose an immediate danger.
A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nägele's rule is:
- A. 27-Mar
- B. 1-Feb
- C. 27-Feb
- D. 3-Jan
Correct Answer: C
Rationale: March 27 is a miscalculation. February 1 is a miscalculation. February 27 is the correct answer. To calculate the estimated date of confinement using Nagele's rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result. January 3 is a miscalculation.
The physician orders fluoxetine (Prozac) for a depressed client. Which of the following should the nurse remember about fluoxetine?
- A. Because fluoxetine is a tricyclic antidepressant, it may precipitate a hypertensive crisis.
- B. The therapeutic effect of the drug occurs 2-4 weeks after treatment is begun.
- C. Foods such as aged cheese, yogurt, soy sauce, and bananas should not be eaten with this drug.
- D. Fluoxetine may be administered safely in combination with monoamine oxidase (MAO) inhibitors.
Correct Answer: B
Rationale: Fluoxetine is not a tricyclic antidepressant. It is an atypical antidepressant. This statement is true. These foods are high in tyramine and should be avoided when the client is taking MAO inhibitors. Fluoxetine is not an MAO inhibitor. Fatal reactions have been reported in clients receiving fluoxetine in combination with MAO inhibitors.
A child with celiac disease is being discharged from the hospital. The mother demonstrates knowledge of nutritional needs of her child when she is able to state the foods which are included in a:
- A. Lactose-restricted diet
- B. Gluten-restricted diet
- C. Phenylalanine-restricted diet
- D. Fat-restricted diet
Correct Answer: B
Rationale: A lactose-restricted diet is prescribed for children with lactose intolerance or diarrhea. A gluten-restricted diet is the diet for children with celiac disease. A phenylalanine-restricted diet is prescribed for children with phenylketonuria. A fat-restricted diet is prescribed for children with disorders of the liver, gallbladder, or pancreas.
A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of:
- A. Afterbirth pains
- B. Constipation
- C. Cystitis
- D. A hematoma of the vagina or vulva
Correct Answer: D
Rationale: Afterbirth pains are a common complaint in the postpartum client, but they are located in the uterus. Constipation may cause rectal pressure but is not usually associated with 'severe pain.' Cystitis may cause pain, but the location is different. Hematomas are frequently associated with severe pain and pressure. Further assessments are indicated for this client.