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A nurse is instructing a patient on the order of sensations with the application of an ice water bath for a swollen right ankle. Which of the following is the correct order of sensations experienced with an ice water bath?
- A. cold, burning, aching, and numbness
- B. burning, aching, cold, and numbness
- C. aching, cold, burning and numbness
- D. cold, aching, burning and numbness
Correct Answer: A
Rationale: CBAN, cold, burn, ache, numbness
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A 57-year-old woman is recently widowed. She states, 'I will never be able to learn how to manage the finances. My husband did all of that.' Select the nurse's response that could help raise the client's self-esteem.
- A. You feel inadequate because you have never learned to balance a checkbook.
- B. You should have insisted your husband teach you about the finances.
- C. You are strong and will learn how to manage your finances after awhile.
- D. Why don't you take a class in basic finance from the local college?
Correct Answer: C
Rationale: The nurse can raise the client's self-esteem by communicating confidence the client can participate in actively finding solutions to the problem. The nurse also conveys the client is a worthwhile person by listening and accepting the client's feelings and praising the client for seeking assistance.
James returns home from school angry and upset because his teacher gave him a low grade on an assignment. After returning home from school, he kicks the dog. This coping mechanism is known as:
- A. denial.
- B. suppression.
- C. displacement.
- D. fantasy.
Correct Answer: C
Rationale: Displacement is the transference of anger to another. Anger is displaced on the dog as a convenient object.
Which of the following statements is correct regarding rape?
- A. Most rapes are reported
- B. Legally, a woman can be raped by her spouse
- C. Prosecution and conviction for rape is easy
- D. The most common location of rape is the victim's own home
Correct Answer: B
Rationale: Spousal rape is legally recognized as non-consensual sexual intercourse within marriage. Most rapes are underreported, prosecution is challenging, and rapes occur in various locations, not predominantly at home.
Which of the following describes the stages of domestic violence in an intimate relationship?
- A. Happiness, crisis, angry outburst, intervention
- B. Honeymoon period, escalation of stress, outburst, reconciliation
- C. Acting out and making up
- D. Peace and calm, angry outburst, peace and calm, denial
Correct Answer: B
Rationale: The cycle of abuse includes a honeymoon phase, stress escalation, an outburst (often violent), and reconciliation, increasing the risk of harm if unaddressed.
A 10-month-old child is brought to the Emergency Department because he is difficult to awaken. The nurse notes bruises on both upper arms. These findings are most consistent with:
- A. wearing clothing that is too small for the child.
- B. the child being shaken.
- C. falling while learning to walk.
- D. parents trying to awaken the child.
Correct Answer: B
Rationale: Children who are shaken are frequently grasped by both upper arms. Symptoms of brain injury associated with shaking include decreased level of consciousness.