Nokea
A nurse is contributing to an in-service for newly-licensed nurses about child maltreatment. The nurse should include that which of the following characteristics increases a child's risk of physical maltreatment?
- A. Low birth weight
- B. Advanced maternal age
- C. Single parenthood
- D. Premature birth
Correct Answer: A
Rationale: Low birth weight increases a child's vulnerability to physical maltreatment due to additional care needs. Advanced maternal age (choice B) is not directly linked to an increased risk of physical maltreatment. Single parenthood (choice C) is not a characteristic that inherently increases the risk of physical maltreatment. Premature birth (choice D) is not listed as a characteristic that directly increases a child's risk of physical maltreatment.
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A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
- A. Administer the medication into the client's nondominant arm.
- B. Pull the skin laterally before inserting the needle.
- C. Massage the injection site after administration.
- D. Pinch the skin between the thumb and forefinger.
Correct Answer: D
Rationale: The correct action the nurse should take when administering enoxaparin subcutaneously is to pinch the skin between the thumb and forefinger. Pinching the skin helps to lift the subcutaneous tissue, reducing the risk of injecting into the muscle. Choices A, B, and C are incorrect. Choice A is not relevant as the injection site for enoxaparin is typically in the abdomen or thigh, not the arm. Choice B is incorrect as pulling the skin laterally is not a recommended technique for subcutaneous injections. Choice C is also incorrect as massaging the injection site after administration can increase the risk of bleeding or bruising.
A nurse is teaching a client who has chronic obstructive pulmonary disease (COPD) about breathing exercises. Which of the following instructions should the nurse include?
- A. Use abdominal breathing during physical activity
- B. Inhale quickly and deeply through the nose
- C. Use pursed-lip breathing during physical activity
- D. Breathe quickly and deeply during exercise
Correct Answer: C
Rationale: The correct answer is C: 'Use pursed-lip breathing during physical activity.' Pursed-lip breathing is a beneficial technique for clients with COPD as it helps improve airflow by keeping the airways open longer. Choice A is incorrect as abdominal breathing may not be as effective in COPD as pursed-lip breathing. Choice B, inhaling quickly and deeply through the nose, is not recommended as it can lead to hyperventilation. Choice D, breathing quickly and deeply during exercise, is also not suitable for clients with COPD as it can cause increased shortness of breath.
A healthcare professional is collecting data from a client who is experiencing post-traumatic stress disorder (PTSD). Which of the following manifestations should the healthcare professional expect?
- A. Hyperactivity
- B. Hypervigilance
- C. Restlessness
- D. Avoidance of social situations
Correct Answer: B
Rationale: Hypervigilance is a common manifestation of PTSD characterized by heightened alertness and fear of danger. This heightened state of awareness can lead to irritability, difficulty concentrating, and sleep disturbances. Choices A, C, and D are incorrect. Hyperactivity is not typically associated with PTSD; restlessness may be present but is not the primary manifestation, and avoidance of social situations is more commonly seen in conditions like social anxiety disorder rather than PTSD.
A healthcare provider is reviewing the medical record of a client who is scheduled for surgery. Which of the following findings should the provider report?
- A. White blood cell count of 8,000/mm³
- B. Potassium level of 4.0 mEq/L
- C. Creatinine level of 1.0 mg/dL
- D. Hemoglobin level of 12 g/dL
Correct Answer: C
Rationale: An elevated creatinine level indicates impaired kidney function, which may affect the client's ability to undergo surgery. The other laboratory values (white blood cell count, potassium level, and hemoglobin level) are within normal ranges and do not directly impact the client's readiness for surgery.
A client is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent dislocation of the prosthesis?
- A. Encourage the client to bend at the waist
- B. Maintain the client in a high-Fowler's position
- C. Place a pillow between the client's legs
- D. Avoid placing a pillow under the client's knees
Correct Answer: C
Rationale: Placing a pillow between the client's legs is beneficial after hip replacement surgery to maintain proper alignment and prevent dislocation of the prosthesis. This position helps keep the hip in a neutral position, reducing the risk of dislocation. Encouraging the client to bend at the waist (Choice A) can increase the risk of hip dislocation. Maintaining the client in a high-Fowler's position (Choice B) and avoiding placing a pillow under the client's knees (Choice D) do not directly address the need to maintain proper alignment of the hip joint to prevent dislocation.