Nokea
As a nurse working in obstetrics, what is one way to mitigate possible causes of intellectual disability?
- A. Explain to the parent the treatment options available.
- B. Explain to the parent environmental risks to avoid during pregnancy.
- C. Explain to the parent that genetics have a role in this disability.
- D. Explain to the parent that learning disabilities often go unnoticed until the child enters school.
Correct Answer: B
Rationale: The correct answer is B because avoiding environmental risks during pregnancy can help mitigate possible causes of intellectual disability. Environmental factors such as exposure to toxins, infections, and poor nutrition can have a significant impact on fetal brain development. By educating parents about these risks, nurses can empower them to make informed choices to protect their baby's cognitive development.
Choice A is incorrect because treatment options are not preventive measures to avoid intellectual disability.
Choice C is incorrect because while genetics can play a role in intellectual disability, it is not something parents can actively mitigate during pregnancy.
Choice D is incorrect because learning disabilities are different from intellectual disabilities, and addressing them at school age is not a preventive measure during pregnancy.
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A client is prescribed disulfiram as part of his alcohol treatment program to prevent relapse. The client asks the nurse, 'How will this drug help me?' Which response by the nurse would be most appropriate?
- A. It will help to cure your alcoholism.'
- B. It can help to prevent you from drinking.'
- C. It makes the withdrawal symptoms less troublesome.'
- D. It helps to clear the alcohol out of your body.'
Correct Answer: B
Rationale: The correct answer is B: It can help to prevent you from drinking. Disulfiram works by causing unpleasant symptoms (such as nausea, vomiting, and headache) when alcohol is consumed, acting as a deterrent to drinking. This helps the client stay sober and avoid relapse.
Incorrect choices:
A: It will help to cure your alcoholism - Disulfiram does not cure alcoholism but helps manage it.
C: It makes the withdrawal symptoms less troublesome - Disulfiram does not address withdrawal symptoms.
D: It helps to clear the alcohol out of your body - Disulfiram does not clear alcohol from the body but rather prevents its metabolism, leading to adverse effects if alcohol is consumed.
A client on a psychiatric unit says,"It's a waste of time to be here. I can't talk to you or anyone." Which would be an appropriate therapeutic nursing response?
- A. "I find that hard to believe."
- B. "Are you feeling that no one understands?"
- C. "I think you should calm down and look on the positive side."
- D. "Our staff here is excellent, and you are in good hands."
Correct Answer: B
Rationale: The correct answer is B because it demonstrates empathy and encourages the client to express their feelings. By asking if the client feels that no one understands, the nurse acknowledges the client's emotions and opens the door for further discussion. Choice A is confrontational and may make the client defensive. Choice C dismisses the client's feelings and is not validating. Choice D is a vague reassurance that does not address the client's concerns.
A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?
- A. The client has surgical hypoparathyroidism and positive Trousseau's sign.
- B. A client who has Clostridium difficile with acute diarrhea
- C. A client who is experiencing acute kidney injury and has urine with a low specific gravity
- D. The client who has oral cancer and reports a sore on his gums
Correct Answer: A
Rationale: The correct answer is A because the client with surgical hypoparathyroidism and positive Trousseau's sign indicates a potential life-threatening condition due to hypocalcemia. Trousseau's sign is a clinical indicator of hypocalcemia, which can lead to serious complications such as seizures and tetany. This client needs immediate intervention to prevent further complications.
Choice B is incorrect because while Clostridium difficile with acute diarrhea requires prompt treatment, it is not as immediately life-threatening as hypocalcemia. Choice C is incorrect as well, as although acute kidney injury is serious, a low specific gravity alone does not necessarily indicate an immediate threat to the client's life. Choice D is also incorrect as oral cancer with a sore on the gums, while concerning, is not an immediate priority compared to the potential life-threatening complications of hypocalcemia.
Which individual is demonstrating the highest level of resilience?
- A. Is able to repress stressors.
- B. Becomes depressed after the death of a spouse.
- C. Lives in a shelter for 2 years after the home is destroyed by fire.
- D. Takes a temporary job to maintain financial stability after loss of a permanent job.
Correct Answer: D
Rationale: The correct answer is D because the individual demonstrates resilience by adapting to adversity and taking proactive steps to maintain financial stability after a setback. This shows a positive coping mechanism and ability to bounce back.
A is incorrect as repressing stressors is not a healthy way of dealing with challenges. B is incorrect as becoming depressed indicates a lack of resilience. C, although a challenging situation, does not necessarily indicate the highest level of resilience as the individual is not actively taking steps to improve their situation.
A nurse has just completed a suicide risk assessment of a 76-year-old widowed man. In addition to documenting the presence or absence of suicidal thoughts, plan, and means, the nurse would also document which of the following?
- A. Use of substances 6 hours before the assessment
- B. Speech patterns
- C. Availability of support resources
- D. Amount of sleep in past 24 hours
Correct Answer: A
Rationale: The correct answer is A: Use of substances 6 hours before the assessment. This is important to assess as substance use can increase the risk of impulsive behavior and exacerbate suicidal thoughts. It is crucial to determine if the individual has recently used substances as it may impact their judgment and decision-making. The other choices are not directly related to immediate risk assessment for suicide. Speech patterns (B) may provide insight into the individual's mental state, but substance use takes precedence in assessing immediate risk. Availability of support resources (C) is important for long-term prevention but does not address immediate risk. The amount of sleep in the past 24 hours (D) may impact mental health but does not directly assess immediate risk of suicide.