Nokea
An elderly client denies that abuse is occurring. Which of the following factors could be a barrier for the client to admit being a victim?
- A. knowledge that elder abuse is rare
- B. personal belief that abuse is deserved
- C. lack of developmentally appropriate screening tools
- D. fear of reprisal or further violence if the incident is reported
Correct Answer: D
Rationale: One of the significant barriers for elderly clients to admit being victims of abuse is the fear of reprisal or further violence if the incident is reported. Elderly individuals may be afraid of the consequences of reporting abuse, such as retaliation or increased violence from the abuser. This fear can prevent them from disclosing their victimization. Choices A and C are incorrect as knowledge of the rarity of elder abuse and the availability of appropriate screening tools do not directly impact the client's willingness to admit abuse. Choice B, personal belief that abuse is deserved, may be a factor for some individuals but is not as common or impactful as the fear of reprisal or further violence.
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A woman asks, "How much alcohol can I safely drink while pregnant?"? The nurse's best response is:
- A. "The amount of alcohol that is safe during pregnancy is unknown."?
- B. "Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman."?
- C. "Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy."?
- D. "You can have a drink to help you relax and get to sleep at night."?
Correct Answer: A
Rationale: The correct answer is, "The amount of alcohol that is safe during pregnancy is unknown."? This response is appropriate because there is no known safe amount of alcohol consumption during pregnancy. Consuming any amount of alcohol during pregnancy can pose risks to the developing fetus, leading to conditions like fetal alcohol syndrome, which is a combination of mental and physical abnormalities in infants. Choices B, C, and D are incorrect. Choice B suggests that consuming one or two drinks a day is safe during pregnancy, which is not supported by current medical guidelines. Choice C incorrectly states that only drinking three or more drinks on any given occasion is harmful, when in reality, any amount of alcohol can be harmful to the fetus. Choice D is inappropriate as it suggests that having a drink to relax and sleep is acceptable during pregnancy, which is not the case.
What should the charge nurse do after overhearing the patient care assistant speaking harshly to the client with dementia?
- A. Change the patient care assistant's assignment
- B. Explore the interaction with the patient care assistant
- C. Discuss the matter with the client's family
- D. Initiate a group session with the patient care assistant
Correct Answer: B
Rationale: The best action for the charge nurse to take is to explore the interaction with the patient care assistant. This step allows for clarification of the situation and direct addressing of the issue. Changing the patient care assistant's assignment (choice A) might be necessary, but understanding the situation should come first. Discussing the matter with the client's family (choice C) as an initial step could escalate the situation. Initiating a group session with the patient care assistant (choice D) could be considered later as a preventive measure to avoid similar incidents in the future.
Which of the following coping mechanisms protects an individual from anxiety?
- A. denial and fantasy
- B. rationalization and suppression
- C. regression and displacement
- D. reaction formation and projection
Correct Answer: A
Rationale: The correct answer is 'denial and fantasy.' Denial involves blocking external events from awareness to avoid anxiety, while fantasy is escaping to a more comfortable, less threatening place. These mechanisms can protect individuals from anxiety by providing temporary relief or distraction. Choices B, C, and D are incorrect. Rationalization and suppression do not directly protect individuals from anxiety. Regression and displacement involve reverting to earlier developmental stages or redirecting emotions to a substitute target, which do not directly shield individuals from anxiety. Reaction formation and projection entail behaving in the opposite way to one's impulses or attributing one's feelings to others respectively, which do not directly protect individuals from anxiety.
During the history assessment of an 80-year-old client, which statement made by the client might indicate a possible fluid and electrolyte imbalance?
- A. "My skin is always so dry."?
- B. "I often use a laxative for constipation."?
- C. "I have always liked to drink a lot of iced tea."?
- D. "I sometimes have a problem with dribbling urine."?
Correct Answer: B
Rationale: The correct answer is "I often use a laxative for constipation." Frequent use of laxatives can lead to diarrhea and electrolyte loss, indicating a possible fluid and electrolyte imbalance. Statements A, C, and D are not directly related to fluid and electrolyte imbalance. Statement A about dry skin may suggest dehydration, but it is less specific to electrolyte imbalance than the frequent use of laxatives. Statement C about drinking a lot of iced tea could potentially relate to fluid intake, but it doesn't directly indicate an imbalance. Statement D about dribbling urine is more indicative of a potential urinary issue rather than a fluid and electrolyte imbalance.
The home health nurse is planning for the day's visits. Which client should be seen first?
- A. The 78-year-old who had a gastrectomy 3 weeks ago with a PEG tube
- B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension
- C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line
- D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
Correct Answer: D
Rationale: The priority client is the 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter. This client is at the highest risk for complications and requires immediate attention. Choice C, the 50-year-old with MRSA being treated with Vancomycin via a PICC line, is incorrect as Vancomycin administration can be scheduled at specific times and does not indicate an urgent need for a visit. Choices A and B are also incorrect as these clients are more stable compared to the client with multiple sclerosis in need of cortisone therapy.