Nokea
Based on the fact that you family unit client is experiencing a situational crisis that has led to dysfunctional communication within the family unit, you have recommended that the entire nuclear family and members of the extended family who live in the family's home begin family therapy. The grandparents tell you that it is their grandson, rather than their son, who is addicted to prescription painkillers, is the cause of the problem; therefore, they do not have to participate in this group therapy. How should you respond to these grandparents?
- A. You should try to come to a few sessions at least because they may be very informative to you'.
- B. You are probably correct. This really is not your problem'.
- C. Despite the fact that it is your grandson's drug addiction, situations such as this affect all members of the family including grandparents who live in the home.'
- D. You should attend because the doctor has ordered family therapy for you as extended family members'.
Correct Answer: C
Rationale: Addiction affects the entire family system, including extended family members living in the home. Their participation in therapy can help address dysfunctional communication and support the family unit as a whole.
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A client with a history of type 1 diabetes is admitted with diabetic ketoacidosis. The nurse should prioritize which of the following interventions?
- A. Administer regular insulin intravenously.
- B. Administer potassium supplements.
- C. Restrict fluid intake.
- D. Administer sodium bicarbonate.
Correct Answer: A
Rationale: Intravenous regular insulin is the priority to lower blood glucose and halt ketogenesis in diabetic ketoacidosis.
Which statement about Respondeat Superior is accurate?
- A. Respondeat Superior does not mean that a nurse cannot be held liable.
- B. Respondeat Superior does not mean that a nurse cannot be held libel.
- C. Respondeat Superior is an ethical principle.
- D. Respondeat Superior is a law.
Correct Answer: A
Rationale: Respondeat Superior is a legal doctrine holding employers liable for employees' actions within the scope of employment, but it does not absolve nurses from personal liability for negligence.
The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when the nurse is
- A. I think I have a bladder infection, I need to see my obstetrician.'
- B. If I have contractions, I should contact my health care provider.'
- C. Drinking water may help prevent early labor for me.'
- D. If I travel on long trips, I need to get out of the car every 4 hours.'
Correct Answer: A
Rationale: Suspecting a bladder infection requires immediate medical evaluation, not just a visit to the obstetrician, as infections can trigger preterm labor. The other statements reflect correct understanding of preterm labor management.
A client with a new colostomy asks the nurse how to prevent skin irritation around the stoma. What is the best response by the nurse?
- A. Apply petroleum jelly around the stoma daily.'
- B. Clean the area with alcohol wipes before applying the pouch.'
- C. Ensure the skin barrier fits snugly and clean with mild soap.'
- D. Change the pouch only once a week.'
Correct Answer: C
Rationale: A snug-fitting skin barrier and cleaning with mild soap prevent skin irritation by protecting the peristomal skin and maintaining hygiene without causing trauma.
A client with a spinal cord injury is at risk for autonomic dysreflexia. Which symptom should the nurse monitor for?
- A. Bradycardia.
- B. Hypotension.
- C. Severe headache.
- D. Increased urine output.
Correct Answer: C
Rationale: Severe headache is a key sign of autonomic dysreflexia, often triggered by bladder or bowel issues.