Nokea
A nurse is counseling a mother with young children after the mother left her abusive husband 6 months ago. The mother says, 'My 6-year-old, Kevin, is starting to act just like his father. I just don't know how to handle this.' Which response by the nurse is most appropriate?
- A. You'll have to limit Kevin's contact with his father.'
- B. Counseling for Kevin would be helpful.'
- C. Most boys outgrow these behaviors.'
- D. Setting limits on his behavior is all you need to do now.'
Correct Answer: B
Rationale: Counseling can help address behavioral issues potentially stemming from trauma or modeling, providing professional support for the child.
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A client with a history of systemic lupus erythematosus (SLE) reports joint pain and fatigue. Which intervention should the nurse prioritize?
- A. Administer analgesics as ordered
- B. Encourage high-impact exercise
- C. Apply cold packs to joints
- D. Restrict fluid intake
Correct Answer: A
Rationale: Administering analgesics addresses joint pain, a common SLE symptom, improving comfort and quality of life.
Which of the following is a priority nursing diagnosis for the client presenting with pelvic inflammatory disease?
- A. Imbalanced nutrition: Less than body requirements.
- B. Bathing/hygiene self-care deficit.
- C. Acute pain.
- D. Impaired skin integrity.
Correct Answer: C
Rationale: Acute pain is the priority diagnosis for pelvic inflammatory disease, as it is a hallmark symptom requiring immediate management.
The client with a burn injury is assessed using the 'rule of nines' to determine which of the following?
- A. Amount of body surface area burned.
- B. Rehabilitation needs.
- C. Respiratory needs.
- D. Type of intravenous fluids required.
Correct Answer: A
Rationale: The rule of nines estimates the percentage of body surface area burned to guide treatment.
When assessing speech development, which of the following children should the nurse refer for further examination?
- A. A 4-month-old who laughs out loud.
- B. A 10-month-old who says 'dada' and 'mama.'
- C. A 1-year-old who says 3 to 5 words.
- D. An 18-month-old who only says 'no.'
Correct Answer: D
Rationale: An 18-month-old should have a vocabulary of about 15-20 words and start forming simple phrases. Only saying 'no' indicates a potential delay, warranting further evaluation. The other options reflect age-appropriate speech milestones.
You are the nurse in an ambulatory surgical center. Which of the following risk factors are associated with impaired and delayed healing?
- A. A lack of zinc
- B. A lack of vitamin E
- C. High iron levels
- D. High phosphorus levels
Correct Answer: A
Rationale: Zinc deficiency impairs wound healing by affecting collagen synthesis and immune function.