Nokea
A nurse is assessing a toddler during a well-child visit. Which of the following findings warrant further investigation?
- A. Bare spots on the scalp, and broken hair
- B. Overly concerned parents
- C. Burns with sharply demarcated edges
- D. Bruises anywhere on the body
Correct Answer: A
Rationale: Bare spots and broken hair, along with burns with sharply demarcated edges, are warning signs of possible child abuse.
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A nurse is caring for a person with a potential dysfunction in the health-perception–health-management pattern. Which of the following nursing interventions would most likely be performed?
- A. Arranging for home delivery of medication from the pharmacy
- B. Providing education regarding the dangers of smoking
- C. Instituting visiting nurse services for blood pressure checks
- D. Providing direct observed therapy for tuberculosis medications
Correct Answer: B
Rationale: Educating clients about the risks, such as smoking, addresses potential health problems and encourages health management.
A liver for which two people are tissue-typed has become available after the death of a donor in a car accident. Client A is a 45-year-old substance abuser whose liver is damaged as a result of his use of alcohol. Client B is a 16-year-old adolescent in need of a liver transplant because of a birth abnormality. Which of the following would be useful for a nurse in giving input as to which of the two should receive the liver?
- A. Advocate for Client B because he is the younger of the two and will live longer.
- B. Use feminist moral theory to advocate for Client A in spite of his alcohol use.
- C. Use a guided set of moral principles in decision-making before advocating for either.
- D. Advocate for Client A because he has 15 to 20 years of productive life left.
Correct Answer: C
Rationale: Using moral principles systematically can help resolve ethical dilemmas and guide decision-making.
A nurse is providing health education for a group of older adults about the risks of developing coronary heart disease. Which of the following group members is at highest risk?
- A. Takes a beta-blocker for hypertension
- B. Has a total cholesterol level of 201
- C. Doesn’t participate in any form of regular physical activity
- D. Has a family history of Type 2 diabetes mellitus
Correct Answer: C
Rationale: Physical inactivity is the biggest modifiable risk factor for coronary heart disease.
A nurse is caring for a pregnant woman who has a pre-pregnancy body mass index (BMI) of 27. Which of the following instructions should the nurse provide the woman regarding weight gain during pregnancy?
- A. “You should gain 11 to 20 pounds during your pregnancy.”
- B. “You should gain 15 to 25 pounds during your pregnancy.”
- C. “You should gain 25 to 35 pounds during your pregnancy.”
- D. “You should gain 28 to 40 pounds during your pregnancy.”
Correct Answer: B
Rationale: Overweight women (BMI 25-29.9) should gain 15-25 pounds during pregnancy.
Reducing Constipation in Older Adults
- A. Offering pureed foods that are easy to digest
- B. Encouraging fluids between meals
- C. Administering laxatives daily
- D. Assisting with ambulation
Correct Answer: B
Rationale: Encouraging fluids and assisting with ambulation are key strategies for preventing constipation in older adults.