Nokea
A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?
- A. A child whose parents answer questions for the child
- B. A child who has frequent visitors
- C. A child who has a BMI indicating obesity
- D. A child who uses the call light frequently
Correct Answer: A
Rationale: The correct answer is A. When parents answer questions for the child, it may indicate a lack of autonomy or control over their own care, suggesting potential abuse or neglect. This behavior can be a red flag for the nurse to further assess the child's situation. Choices B, C, and D do not necessarily indicate abuse. Frequent visitors could be a sign of social support, obesity may be due to various factors, and using the call light frequently may indicate medical needs rather than abuse. It is essential for the nurse to explore further if a child's autonomy is being compromised.
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A nurse is interviewing a school-age child who has intermittent explosive disorder (IED). Which of the following behaviors should the nurse expect the client to exhibit?
- A. Lack of remorse for behavior
- B. Mild outbursts with provocation
- C. Blaming others for their behavior
- D. Difficulty coping with stressors
Correct Answer: A
Rationale: The correct answer is A: Lack of remorse for behavior. In intermittent explosive disorder (IED), individuals exhibit sudden and intense episodes of aggression or violence. They may act impulsively without considering consequences or feeling remorse afterward. This lack of remorse is a key characteristic of IED, distinguishing it from other behavioral disorders like conduct disorder where remorse might be present. Choices B, C, and D are incorrect because mild outbursts with provocation, blaming others for behavior, and difficulty coping with stressors are not specific to IED but can be seen in various other behavioral disorders or stress-related conditions.
A nurse is caring for a client who is refusing to attend group therapy. The client states,I don't know why you think I need therapy. I am fine without it. Which of the following responses by the nurse indicates a therapeutic response?
- A. I understand that you feel like you don't need it; however, the provider thinks it will help.
- B. You don't feel like group therapy is for you. Tell me more about what you know about group therapy.
- C. I am not saying that you need therapy, but I am sure it will help you.
- D. You don't have to be afraid to go. Our therapists are very understanding.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Option B demonstrates therapeutic communication by showing empathy and understanding towards the client's feelings and inviting further discussion. By encouraging the client to express their thoughts on group therapy, the nurse opens up a dialogue to explore the client's beliefs and concerns, fostering trust and rapport. This approach respects the client's autonomy and promotes client-centered care.
Summary of Incorrect Choices:
A: This response dismisses the client's feelings and focuses on the provider's opinion, potentially alienating the client and not addressing their concerns.
C: This response minimizes the client's feelings and imposes the nurse's beliefs, which may lead to resistance and hinder the therapeutic relationship.
D: This response invalidates the client's emotions by assuming fear as the underlying issue and may create defensiveness rather than addressing the client's actual concerns.
A nurse is providing teaching to a client diagnosed with schizophrenia and is prescribed haloperidol (Haldol). Which of the following information should the nurse include in the teaching?
- A. This medication will decrease your symptoms of OCD.
- B. This medication may cause excessive salivation.
- C. You can stop taking the medication if the side effects are bothersome.
- D. You may experience dizziness upon standing while taking this medication.
Correct Answer: D
Rationale: The correct answer is D: You may experience dizziness upon standing while taking this medication. This is important information to include because haloperidol can cause orthostatic hypotension, leading to dizziness upon standing. This is a common side effect that the client should be aware of to prevent falls. Option A is incorrect because haloperidol is not used to treat OCD. Option B is incorrect because excessive salivation is not a common side effect of haloperidol. Option C is incorrect because it is crucial not to stop taking antipsychotic medications abruptly without consulting a healthcare provider.
A nurse is educating a 28-year-old female client about the impacts of hypothyroidism on overall health. Which of the following statements would the nurse include in the teaching?
- A. If you become pregnant, low thyroid hormone levels can affect your developing fetus.
- B. Hypothyroidism can cause autoimmune disorders over time.
- C. Low thyroid hormone levels will cause your metabolism to speed up and heart rate to increase.
- D. Low blood pressure is usually associated with hypothyroidism.
Correct Answer: A
Rationale: Rationale: The correct answer is A because hypothyroidism, characterized by low thyroid hormone levels, can lead to complications during pregnancy, affecting fetal development. This is due to the essential role of thyroid hormones in fetal brain and nervous system development.
Summary of Incorrect Choices:
B: Hypothyroidism is linked to autoimmune disorders, not a consequence of it.
C: Hypothyroidism actually slows down metabolism and heart rate due to decreased thyroid hormone levels.
D: Low blood pressure is more commonly associated with hyperthyroidism, where the thyroid is overactive.
A nurse is teaching a newly licensed nurse about heparin-induced thrombocytopenia. Which of the following risk factors for this disorder should the nurse include in the teaching?
- A. Systemic lupus erythematosus
- B. Placental abruption
- C. Heparin therapy for deep-vein thrombosis
- D. Warfarin therapy for atrial fibrillation
Correct Answer: C
Rationale: Rationale: Heparin-induced thrombocytopenia (HIT) is a rare but serious complication of heparin therapy, causing a drop in platelet count. The correct answer is C because heparin therapy for deep-vein thrombosis is a known risk factor for HIT. Systemic lupus erythematosus (choice A) is associated with other complications but not specifically HIT. Placental abruption (choice B) is a condition related to pregnancy complications. Warfarin therapy for atrial fibrillation (choice D) is not a risk factor for HIT. Therefore, the nurse should focus on heparin therapy as a significant risk factor in HIT education.