Nokea
When a client describes their family as having multiple wives, all of whom are sisters, married to one man, the nurse documents the family structure as?
- A. polyandry
- B. sororal
- C. nonsororal
- D. soronal
Correct Answer: D
Rationale: The correct answer is 'soronal.' The practice of polygamy refers to having multiple wives or husbands. When there are multiple wives who are sisters, the polygamy is designated as sororal. Polyandry refers to multiple husbands, which is rare. Nonsororal polygamy is when the wives are not sisters. Sororate polygamy specifies that a husband must marry his wife’s sister if she dies. Therefore, in this scenario, the family structure described by the client fits the definition of soronal polygamy.
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A sexually active married couple, discussing birth control methods with the nurse, expresses the need for a method that is convenient. Because the couple has told the nurse that family-planning goals have been met, which method of birth control does the nurse suggest?
- A. Diaphragm
- B. Sterilization
- C. Male condom
- D. Spermicide
Correct Answer: B
Rationale: In this scenario, since the couple has indicated that their family-planning goals have been met, a permanent method of contraception like sterilization would be most suitable. Sterilization offers long-term effectiveness and convenience once the decision to stop having children is made. Options like the diaphragm, male condom, or spermicide are more suitable for temporary contraception or when the family-planning goals have not yet been achieved. Therefore, the correct answer is sterilization, as it aligns with the couple's need for a convenient and permanent birth control method.
A client can receive the Mumps, Measles, Rubella (MMR) vaccine if he or she:
- A. is pregnant.
- B. is immunocompromised.
- C. is allergic to neomycin.
- D. has a cold.
Correct Answer: D
Rationale: A client can receive the MMR vaccine if he or she has a cold without a fever since it does not preclude vaccination. Pregnant women and immunocompromised individuals cannot receive the MMR vaccine because the rubella component is a live virus that may cause birth defects and/or disease. Being allergic to neomycin is also a contraindication as per the American Academy of Pediatrics guidelines. Individuals who have experienced anaphylactic reactions to neomycin should not receive the measles vaccine. Therefore, option D 'has a cold' is the correct choice, as the presence of a simple cold does not prevent the client from receiving the MMR vaccine.
A nurse is interviewing an older adult while assisting with data collection. Which client comment regarding vision requires immediate discussion with the health care provider?
- A. "If I go from a very bright room to a very dark room, I have some trouble adjusting."
- B. "I have to hold my newspaper farther and farther away from me when I read."
- C. "I have a little trouble telling if my same-colored shirts and blouses actually match; the colors seem the same to me."
- D. "It looks like I have a blank spot in the middle of what I'm trying to see."
Correct Answer: D
Rationale: The correct answer is "It looks like I have a blank spot in the middle of what I'm trying to see." Seeing blank spots in the middle of an object is a sign of central vision loss, which is a symptom of macular degeneration. Macular degeneration is a serious condition that requires immediate discussion with a healthcare provider to prevent further vision loss. Choice A, mentioning difficulty adjusting between bright and dark rooms, is a common issue related to changes in lighting and not a cause for immediate concern. Choice B, having to hold objects farther away when reading, is indicative of presbyopia, a normal age-related change in vision. Choice C, experiencing slight changes in color perception, is also a common age-related change and not an urgent issue that necessitates immediate discussion with a healthcare provider.
A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR?
- A. Stethoscope
- B. Doppler transducer
- C. Fetoscope
- D. Pulse oximetry on the client and a fetoscope
Correct Answer: B
Rationale: To assess the fetal heart rate of a client who is 14 weeks pregnant, the nurse should use a Doppler transducer. Fetal heart sounds can be heard with a fetoscope by 20 weeks of gestation. The Doppler transducer amplifies fetal heart sounds so that they are audible by 10 to 12 weeks of gestation, making it the most appropriate choice for this scenario. Fetal heart sounds cannot be heard with a stethoscope. Pulse oximetry is not used to auscultate fetal heart sounds, so it is an incorrect choice in this context.
A nurse observes a nursing assistant communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the nursing assistant performs which action?
- A. Uses short sentences
- B. Speaks at a normal rate and volume
- C. Uses facial expressions or gestures
- D. Overarticulates words
Correct Answer: D
Rationale: The correct answer is 'Overarticulates words.' When communicating with a hearing-impaired client who may rely on lip-reading, it is essential to speak clearly at a normal rate and volume. Overarticulating words can distort lip movements, making it harder for the client to understand. Using short sentences helps in conveying information effectively, allowing the client time to process. While facial expressions and gestures provide additional visual cues that aid in communication, overarticulating words can be counterproductive in this scenario. Therefore, the nursing assistant should avoid overarticulating words to ensure clear and concise communication for the client.