Nokea
A young boy tells the nurse, 'I don't like my Dad to kiss or hug my Mom. I love my Mom and want to marry her.' The nurse recognizes this stage of growth and development as:
- A. Electra complex
- B. Oedipus complex
- C. Superego
- D. Ego
Correct Answer: B
Rationale: The Oedipus complex involves a young boy's erotic attachment to his mother and jealousy toward his father.
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The nurse is assessing a client with suspected anaphylactic shock. Which intervention is the priority?
- A. Administer epinephrine
- B. Start an IV fluid bolus
- C. Place the client in Trendelenburg position
- D. Administer oxygen via nasal cannula
Correct Answer: A
Rationale: Epinephrine is the priority in anaphylactic shock to reverse bronchoconstriction and hypotension. IV fluids and oxygen are secondary, and Trendelenburg is not recommended.
An appropriate nursing intervention for the client with borderline personality disorder is:
- A. Observing the client for signs of depression or suicidal thinking
- B. Allowing the client to lead unit group sessions
- C. Restricting the client's activity to the assigned unit of care throughout hospitalization
- D. Allowing the client to select a primary caregiver
Correct Answer: A
Rationale: Clients with borderline personality disorder often experience mood instability and are at risk for self-harm or suicide. Observing for signs of depression or suicidal thinking is a priority nursing intervention to ensure safety. Allowing the client to lead group sessions or select a caregiver may reinforce manipulative behaviors, and restricting activity to the unit is not typically therapeutic unless specified for safety.
The nurse is caring for a client with a history of a stroke who has hemiparesis. The nurse should:
- A. Position the client on the strong side
- B. Encourage passive range of motion
- C. Provide a high-protein diet
- D. Use a sling for the affected arm
Correct Answer: D
Rationale: A sling supports the affected arm in hemiparesis, preventing subluxation. Positioning varies, passive motion is secondary, and diet depends on needs.
An amniocentesis at 32 weeks gestation reveals that a multigravida with diabetes has an L/S ratio of 1:1 with the presence of phosphatidylglycerol. Based on the amniocentesis,the nurse knows that if delivered now:
- A. The newborn is at low risk for congenital anomalies.
- B. The newborn is at high risk for intrauterine growth retardation.
- C. The newborn is at high risk for respiratory distress syndrome.
- D. The newborn is at high risk for birth trauma.
Correct Answer: C
Rationale: An L/S ratio of 1:1 at 32 weeks indicates immature fetal lungs increasing the risk of respiratory distress syndrome (RDS) if delivered now. Phosphatidylglycerol presence is positive but does not fully mitigate RDS risk. The other risks are not directly related to the L/S ratio.
A client with a history of a stroke is being taught to use a cane. The nurse should teach the client to:
- A. Hold the cane in the strong hand
- B. Advance the cane with the strong leg
- C. Use the cane on the weak side
- D. Lean heavily on the cane while walking
Correct Answer: C
Rationale: The cane should be used on the weak side to support the affected leg, improving balance and gait post-stroke. Holding it in the strong hand or advancing with the strong leg is incorrect.