Nokea
A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of the following statements indicates an understanding by the newly licensed nurse?
- A. "Evidence must exist prior to reporting."
- B. "If the potential abuser commits to stopping the abuse, health care workers are not required to report it."
- C. "I don't want to defame someone if the report is false."
- D. "If suspicion of abuse exists, then reporting is mandatory."
Correct Answer: D
Rationale: The correct answer is D: "If suspicion of abuse exists, then reporting is mandatory." This statement is correct because as a healthcare professional, it is crucial to report any suspicion of child abuse to protect the child's safety. Reporting is mandatory to ensure that appropriate actions are taken to investigate and prevent harm to the child.
A: "Evidence must exist prior to reporting." - This statement is incorrect because suspicion alone is enough to trigger reporting, and waiting for evidence may delay intervention and put the child at risk.
B: "If the potential abuser commits to stopping the abuse, health care workers are not required to report it." - This statement is incorrect as it is the responsibility of healthcare workers to report suspected abuse regardless of promises made by the potential abuser.
C: "I don't want to defame someone if the report is false." - This statement is incorrect because the focus should be on the safety and well-being of the child, and reporting suspicions of abuse is not about def
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A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication?
- A. Thyroid function tests should be performed every 6 months.
- B. A pretreatment electroencephalogram (EEG) will be done.
- C. Liver function tests should be monitored.
- D. High serum sodium levels can cause toxic levels of valproate.
Correct Answer: C
Rationale: Valproate is metabolized in the liver, requiring regular liver function monitoring.
A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements should the nurse make?
- A. "You should be aware that excessive sleeping is an early sign of relapse."
- B. "Relapse is an indication that you are not taking your medications properly."
- C. "You should keep your provider's and therapist's number with you."
- D. "Taking an additional dose of medication is appropriate as soon as signs of relapse appear."
Correct Answer: C
Rationale: The correct answer is C because keeping the provider's and therapist's number with the client is crucial for quick access to support during a potential relapse. This step promotes timely intervention and communication with the healthcare team, which can help prevent escalation of symptoms. Option A is incorrect because excessive sleeping may not be a universal early sign of relapse for all individuals with schizophrenia. Option B is incorrect because relapse can occur despite proper medication adherence. Option D is incorrect because self-medicating without healthcare provider guidance can be dangerous and may worsen symptoms.
A nurse is caring for a client who has major depressive disorder. Which of the following findings should the nurse expect?
- A. Dismissal of past failures
- B. Psychomotor agitation
- C. An increase in energy
Correct Answer: B
Rationale: The correct answer is B: Psychomotor agitation. In major depressive disorder, psychomotor agitation is a common symptom characterized by restlessness, pacing, fidgeting, or hand-wringing. This is due to the increased inner tension and anxiety experienced by the individual. Dismissal of past failures (A) is not a typical finding in major depressive disorder, as individuals often dwell on negative thoughts. An increase in energy (C) is unlikely, as fatigue and low energy levels are more common in depression. The other choices are not provided, but it's important to remember that psychomotor agitation can be a key indicator in identifying major depressive disorder.
A nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?
- A. "It's okay to feel scared. Let's talk about what you are afraid of."
- B. "Don't worry. The important thing is you have now quit smoking."
- C. "I understand your fears. I was a smoker also."
- D. "Your doctor is a great surgeon. You will be fine."
Correct Answer: A
Rationale: The correct answer is A: "It's okay to feel scared. Let's talk about what you are afraid of." This response shows empathy and acknowledges the client's feelings, which is an essential aspect of therapeutic communication. By inviting the client to talk about her fears, the nurse creates a safe space for the client to express her emotions and concerns. This can help alleviate anxiety and build trust between the client and the nurse.
Choices B, C, and D are incorrect because they do not directly address the client's emotional state or offer support. B focuses on smoking cessation, which may not be the immediate concern for the client undergoing surgery. C shifts the focus to the nurse's personal experience, which may detract from the client's needs. D dismisses the client's fears and offers reassurance without addressing the underlying emotions.
A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?
- A. Ask the client for permission to take photographs.
- B. Document the client's verbatim statements.
- C. Provide community sexual assault support contacts.
- D. Determine any physical signs of injury.
Correct Answer: D
Rationale: The correct answer is D: Determine any physical signs of injury. This should be the first action taken by the nurse in this situation because assessing for physical signs of injury is crucial for ensuring the client's immediate safety and well-being. By assessing for physical injuries, the nurse can prioritize medical treatment if needed and gather important forensic evidence. This initial assessment also helps in determining the urgency of the situation and guides the next steps in providing appropriate care and support.
Choices A, B, and C are incorrect as they are not the priority in this situation. Asking for permission to take photographs, documenting verbatim statements, and providing community sexual assault support contacts are important actions but should come after ensuring the client's immediate physical well-being is addressed. It is essential to focus on the client's physical safety and health first before moving on to other aspects of care and support.