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A nurse is assessing a child in the emergency department. Which of the following findings places the child at the greatest risk for physical abuse?
- A. The child is 10 years old
- B. The child is home-schooled
- C. The child has no siblings
- D. The child has cystic fibrosis
Correct Answer: A
Rationale: The correct answer is A: The child is 10 years old. Children between 8-12 years old are at higher risk for physical abuse due to increased independence and potential conflicts with caregivers. Being 10 years old puts the child at a critical age for abuse. Choice B (home-schooled) does not directly correlate with an increased risk of abuse. Choice C (no siblings) does not indicate abuse risk. Choice D (cystic fibrosis) is a medical condition and does not specifically increase the risk of physical abuse.
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A nurse in a psychiatric facility is planning care for a client who has depression and is at risk for suicide. Which of the following interventions should the nurse implement?
- A. Assign the same staff to the client each shift
- B. Keep the client's room well-lit at all times
- C. Allow the client privacy at all times
- D. Provide access to sharp objects
Correct Answer: A
Rationale: The correct answer is A: Assign the same staff to the client each shift. Consistency in staff helps build trust and rapport, crucial for clients with depression and suicide risk. This continuity allows staff to better monitor the client's behavior, mood changes, and suicide risk factors. The familiarity also helps in identifying early warning signs and implementing appropriate interventions promptly.
Choice B is incorrect because while keeping the room well-lit may help prevent self-harm, it does not address the underlying need for consistent support and monitoring.
Choice C is incorrect as constant privacy may hinder the nurse's ability to assess the client's safety and intervene effectively.
Choice D is incorrect as providing access to sharp objects increases the client's risk of self-harm.
A nurse in a community clinic is planning an educational session for a group of clients. Which of the following strategies should the nurse use when teaching about stress management?
- A. Provide lengthy lectures on stress
- B. Encourage discussion and practice of coping skills
- C. Discourage clients from expressing emotions
- D. Teach all clients the same stress-reduction technique
Correct Answer: B
Rationale: The correct answer is B: Encourage discussion and practice of coping skills. This strategy is effective because it actively engages clients in learning and applying coping mechanisms, promoting better retention and skill development. By encouraging discussion, clients can share experiences and support each other, enhancing their understanding and motivation. Practicing coping skills helps clients to internalize and apply them in real-life situations.
Incorrect choices:
A: Providing lengthy lectures is less effective as it can be overwhelming and may not actively involve clients in learning.
C: Discouraging clients from expressing emotions hinders the therapeutic process and can lead to bottling up emotions, increasing stress.
D: Teaching all clients the same technique may not address individual needs and preferences, limiting the effectiveness of stress management strategies.
A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the following findings should the nurse anticipate administration of lorazepam?
- A. Bradycardia
- B. Stupor
- C. Afebrile
- D. Hypertension
Correct Answer: D
Rationale: The correct answer is D: Hypertension. Lorazepam is a benzodiazepine commonly used to manage alcohol withdrawal symptoms, including hypertension. Alcohol withdrawal often leads to increased sympathetic nervous system activity, causing elevated blood pressure. Lorazepam helps to reduce this symptom by promoting relaxation and reducing anxiety. Bradycardia (A), stupor (B), and afebrile (C) are not indications for lorazepam administration in alcohol withdrawal. Bradycardia and stupor may require further evaluation for potential complications, while afebrile state does not directly warrant lorazepam use.
A nurse is providing discharge teaching to the parents of a child who has ADHD and a prescription for methylphenidate. Which of the following instructions should the nurse include?
- A. Administer the medication at bedtime
- B. Monitor the child’s weight frequently
- C. Give the medication with milk
- D. Discontinue the medication if insomnia occurs
Correct Answer: B
Rationale: The correct answer is B: Monitor the child’s weight frequently. This is important because methylphenidate, a stimulant used to treat ADHD, can potentially lead to appetite suppression and weight loss in children. Regular monitoring of the child's weight can help identify any significant changes and allow for appropriate interventions if needed.
Choice A is incorrect because administering the medication at bedtime can lead to insomnia due to its stimulant effects. Choice C is incorrect as there is no specific recommendation to give the medication with milk. Choice D is incorrect because insomnia is a common side effect of methylphenidate and does not necessarily warrant discontinuation of the medication unless severe or persistent.
A nurse in a community mental health clinic is caring for a group of clients. The nurse should encourage participation in cognitive behavioral family therapy in response to which of the following client statements?
- A. I want to learn how to change the way I react to problems within my family
- B. I want to understand why my past experiences are affecting my family relationships
- C. I want to improve my family’s understanding of each other’s boundaries
- D. I want each of my family members to be more aware of each other’s feelings
Correct Answer: A
Rationale: The correct answer is A because cognitive behavioral family therapy focuses on changing negative thought patterns and behaviors. By wanting to change the way they react to family problems, the client is demonstrating a readiness to engage in cognitive restructuring and behavioral change. Choice B is incorrect as it pertains more to individual therapy exploring past experiences. Choice C is incorrect as it focuses on improving understanding of boundaries, which is not the primary goal of cognitive behavioral family therapy. Choice D is incorrect because it emphasizes awareness of feelings rather than addressing reactive behaviors.