Nokea
A victim of domestic violence states to the nurse, 'If only I could change and be how my companion wants me to be, I know things would be different.' Which would be the best response by the nurse?
- A. The violence is temporarily caused by unusual circumstances, don't stop hoping for a change.
- B. Perhaps, if you understood the need to abuse, you could stop the violence.
- C. No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?
- D. Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do.
Correct Answer: D
Rationale: Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do. This clarifies that the abuser is responsible for the violence.
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A client with an irregular pulse rate of 81 and a potassium level of 3.0 mEq/L has digoxin (Lanoxin) ordered.
Which of the following actions if taken by the nurse is BEST?
- A. Give the digoxin.
- B. Hold the digoxin.
- C. Notify the physician.
- D. Re-check the pulse.
Correct Answer: C
Rationale: Strategy: The topic of the question is unstated. (1) although the pulse is normal, level of potassium must be considered (2) notify physician about low potassium (3) correct-hypokalemia can precipitate digoxin toxicity; physician should be called to obtain order for potassium supplement (4) notify physician about the potassium level
A client comes to the emergency room with complaints of 'numbness, tingling, and coldness' of her left leg. She is able to walk. You note that the skin appears pale and is cool to the touch. What should the nurse do first?
- A. Ask if she had had a similar condition in her arms or the other leg
- B. Notify the physician immediately
- C. Obtain a detailed nursing health history
- D. Palpate and record the femoral, popliteal, posterior tibial, and dorsalis pedis pulses in the affected leg
Correct Answer: D
Rationale: Palpating pulses assesses for arterial occlusion, the priority to determine the cause of numbness and coldness, guiding urgent intervention.
The nurse is caring for an adult who had a nephrectomy this morning. Because of the location of the surgery, the nurse knows that the client is at increased risk for which of the following?
- A. Thrombophlebitis
- B. Wound infection
- C. Atelectasis
- D. Footdrop
Correct Answer: C
Rationale: Nephrectomy involves flank incision near the diaphragm; postoperative pain limits deep breathing, increasing atelectasis risk. Thrombophlebitis, infection, or footdrop are less specific to the site.
A 26-year-old woman is admitted to the neurosurgery unit for the removal of a cerebellar tumor.
The nurse would expect the patient to make which of the following statements about her symptoms?
- A. I have been having difficulty with my hearing.'
- B. I lose my balance easily.'
- C. I can't tell the difference between a sweet and sour taste.'
- D. It is not easy for me to remember names and faces.'
Correct Answer: B
Rationale: Strategy: Remember physiology. (1) temporal lobe contains auditory center, loss of hearing would involve CN VIII acoustic (2) correct-cerebellum maintains balance (3) CN IX, glossopharyngeal responsible for differentiation of taste (4) not specific symptoms of cerebellum dysfunction
A six-year-old boy with a history of epilepsy admitted with uncontrolled seizures.
It is MOST important for the nurse to ask which of the following questions?
- A. What part of the body was affected by the seizure?'
- B. What is the family history of seizure disorders?'
- C. What was your son doing before the seizure?'
- D. How long has it been since his last episode of seizures?'
Correct Answer: C
Rationale: Strategy: 'MOST important' indicates that this is a priority question. (1) not most important question (2) should be included in detailed history, but will not prevent an immediate reoccurrence (3) correct-seizure may result from triggering mechanism (loud noise, music, flickering light, prolonged reading, drugs) (4) should be included in detailed history, but will not prevent an immediate reoccurrence