Nokea
As the nurse in a primary care clinic, which cultural concern would you integrate into your psychological assessments of your clients?
- A. The concern related to the client's cultural reluctance to report psychological symptoms because of some possible culturally based stigma associated with psychiatric mental health disorders
- B. Concerns revolving around the lack of financial and health insurance resources to pay for psychological care
- C. Concerns related to the compliance with psychological treatment regimens because of the client's lack of social support systems
- D. The concern related to the culturally based client apathy about nursing care and nursing assessments
Correct Answer: A
Rationale: Cultural stigma around mental health can significantly impact clients' willingness to report psychological symptoms, making it a critical consideration in assessments.
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The nurse is caring for a client with a history of burns. Which of the following psychosocial interventions should be included in the plan of care?
- A. Encourage expression of feelings.
- B. Restrict family visits.
- C. Limit social interactions.
- D. Provide sedatives routinely.
Correct Answer: A
Rationale: Encouraging expression of feelings supports emotional coping in burn recovery.
A client is suspected of having a slow gastrointestinal bleed. The nurse should evaluate the client for which sign or symptom?
- A. Increased pulse.
- B. Nausea.
- C. Tarry stools.
- D. Abdominal cramps.
Correct Answer: C
Rationale: Tarry stools are a hallmark sign of a slow gastrointestinal bleed due to digested blood.
While obtaining the vital signs on a mother who delivered a healthy newborn 2 hours ago the nurse notes that the mother's temperature is 102°F. Which is the appropriate nursing action at this time?
- A. Notify the primary health care provider.
- B. Remove the blanket from the client's bed.
- C. Document the finding and recheck the temperature in 4 hours.
- D. Administer acetaminophen and recheck the temperature in 4 hours.
Correct Answer: A
Rationale: Vital signs usually return to normal within the first hour postpartum if no complications arise. A slight elevation in the temperature may be noted if the client is experiencing dehydrating effects that can occur from labor. A temperature of 102°F indicates infection, and the primary health care provider should be notified. The remaining options are inaccurate nursing interventions for a temperature of 102°F 2 hours after delivery.
The nurse is caring for a client with a history of venous insufficiency. Which of the following interventions is most appropriate?
- A. Encourage prolonged standing.
- B. Apply compression stockings.
- C. Keep the legs in a dependent position.
- D. Limit fluid intake.
Correct Answer: B
Rationale: Compression stockings improve venous return and reduce swelling in venous insufficiency.
A client with a history of anxiety disorder is prescribed buspirone (BuSpar). The nurse should explain that this medication:
- A. Works immediately to reduce anxiety.
- B. May take 2-4 weeks to achieve full effect.
- C. Should be taken with grapefruit juice.
- D. Is addictive and requires tapering.
Correct Answer: B
Rationale: Buspirone typically takes 2-4 weeks to achieve its full anti-anxiety effect, unlike benzodiazepines.