Nokea
A middle-aged woman is brought to the emergency room after being raped in her home. The client asks the nurse to call her husband to come to the emergency room. The nurse knows that the most common reaction of significant others to a rape victim is reflected in which of the following statements?
- A. Supportive and helpful to the victim.
- B. Disconnected and apathetic toward the victim.
- C. Frustrated and feeling vulnerable, but denying need for help.
- D. Emotionally distressed and needing assistance.
Correct Answer: D
Rationale: sexual assault by rape is a crisis situation for both victim and family members and friends
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The nurse is instructing a client being discharged on tranylcypromine sulfate (Parnate).
The nurse knows further instruction is needed if the client makes which of the following statements?
- A. To celebrate, my wife and I are going out for pepperoni pizza and wine tonight.'
- B. I plan to use sunblock at the beach this summer.'
- C. When I get home, I am going to start a diet so I can lose some weight.'
- D. Now that I feel so much better, I have more energy.'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to Parnate. (1) correct-Parnate is a MAO inhibitor; must avoid food with tyramine (aged cheese, yogurt, beer, wine) to prevent hypertensive crisis (2) sunblock required (3) no contraindication to sensible weight reduction diet (4) expected outcome of antidepressant; takes 3-4 weeks to work
The nurse is teaching a client who is preparing to breast-feed. What is the best approach to promote successful breast-feeding?
- A. Give her a pamphlet on breast-feeding
- B. Discuss the advantages of breast milk
- C. Assist her to position the newborn at the breast
- D. Tell her to always breast-feed when the infant cries
Correct Answer: C
Rationale: Assist her to position the newborn at the breast. While all of the responses are helpful in teaching, the priority is placing the infant to breast as soon after birth as possible to establish contact and allow the newborn to begin to suck.
A four-year-old child with sickle cell anemia.
The nurse is aware that which of the following statements, if made by the parents of a four-year-old child with sickle cell anemia, indicates a need for further teaching?
- A. When my daughter complains of pain, I give her baby aspirin.'
- B. I try to keep my daughter away from people with infections.'
- C. I sometimes have to give my daughter some of her Demerol for pain.'
- D. I encourage my daughter to drink a lot of water.'
Correct Answer: A
Rationale: Strategy: 'Need for further teaching' indicates you are looking for an incorrect behavior. (1) correct-aspirin can cause a hemorrhage during a sickle cell crisis (2) important for a sickle cell client to prevent sickling crisis (3) reflects appropriate use of medication to decrease the client's pain (4) important for a sickle cell client to prevent sickling crisis
The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member is
- A. Advising client to restrict sodium intake
- B. Taking the blood pressure in the left arm
- C. Elevating her left arm above heart level
- D. Compressing the drainage device
Correct Answer: B
Rationale: Taking the blood pressure in the left arm. Clients who have had a unilateral mastectomy should not have their blood pressure measured on the affected side. This helps avoid the possibility of lymphedema post-operatively and in the future.
The nurse is planning care for a client with a long history of smoking and newly diagnosed chronic obstructive pulmonary disease (COPD). Which of the following should the nurse include in the client's teaching plan?
- A. Explain the need to avoid large crowds during the winter months.
- B. Instruct the client to install air conditioning in the home.
- C. Teach the client to breathe in through the nose and out through the mouth.
- D. Encourage the client to consume three large meals daily.
Correct Answer: A
Rationale: Clients with COPD are at high risk for respiratory infections, which can exacerbate symptoms. Avoiding large crowds during winter reduces exposure to viruses. Options B, C, and D are less relevant: air conditioning is not essential, nasal breathing is not specific, and large meals can cause dyspnea due to gastric pressure.