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Charles, the nurse, is working in an emergency department and is assessing a preschool-age child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse (select all that apply)
- A. Areas of ecchymosis on the torso.
- B. Mismatched clothing
- C. Abrasions on knees
- D. Abdominal rebound tenderness
- E. Round burn marks on forearms
Correct Answer: A,E
Rationale: The correct answers are A and E. Ecchymosis on the torso may indicate physical abuse, and burn marks on the forearms suggest possible abuse as well. Mismatched clothing (B) is not a direct indicator of abuse but may suggest neglect. Abrasions on knees (C) are common in preschool-age children and do not specifically point to abuse. Abdominal rebound tenderness (D) is a medical finding that may indicate a health issue but does not directly correlate with abuse. Overall, A and E are the most concerning findings that should alert the nurse to possible abuse.
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A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? (Select all that apply.)
- A. Impulsive behaviors
- B. Sleeping for long periods of time
- C. Interacting with others in a flirtatious way
- D. Dressing in black or grey clothing
- E. Talking in rapid,continuous speech
Correct Answer: A,C,E
Rationale: The correct answers are A, C, and E. Impulsive behaviors, interacting flirtatiously, and talking rapidly are classic manifestations of manic behavior in bipolar disorder. Impulsive actions can lead to risky behaviors. Flirtatious interactions are often inappropriate and lack boundaries. Rapid, continuous speech is a hallmark of mania, reflecting racing thoughts and pressured speech. Choices B and D do not align with manic behavior. Sleeping for long periods is more indicative of depression, while dressing in black or grey clothing does not directly correlate with manic episodes.
A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches,the client states I am at the end of my rope. I don’t think I can take any more bad news. Which of the following responses should the nurse make?
- A. An anti-anxiety pill works best for situations like this.
- B. Most clients with anxiety issues benefit from lying down.
- C. Providers usually recommend relaxation exercises for clients who are as upset as you are.
- D. Come with me to an area where we can talk without interruption.
Correct Answer: D
Rationale: Inviting the client to a quiet area offers support and encourages expression of concerns.
A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as possible risk factors for iron deficiency anemia?
- A. The client eats red meat daily.
- B. The client has had gastric bypass surgery.
- C. The client has had treatment for gastrointestinal cancer.
- D. The client eats mostly prepackaged,processed foods.
- E. The client has ulcerative colitis.
Correct Answer: B,C,D,E
Rationale: The correct answer includes choices B, C, D, and E. Gastric bypass surgery can lead to malabsorption of iron, increasing the risk of anemia. Treatment for gastrointestinal cancer can also affect iron absorption. Eating mostly prepackaged, processed foods may lack iron-rich foods, contributing to anemia risk. Ulcerative colitis can cause intestinal bleeding, leading to iron deficiency. Choice A is incorrect as red meat is a good source of iron.
A client has made the decision to leave her alcoholic husband and reports feeling very depressed. Which of the following is a non-therapeutic statement by the nurse that demonstrates sympathy?
- A. You are feeling very depressed. I felt the same way when I decided to leave my husband.
- B. I can understand you are feeling depressed. It was a difficult decision. I'll sit with you.
- C. You seem depressed. It was a difficult decision to make. Would you like to talk about it?
- D. I know this is a difficult time for you. Would you like medication for anxiety?
Correct Answer: A
Rationale: The correct answer is A because the nurse is sharing her personal experience, which is not therapeutic as it shifts the focus from the client to the nurse's own experience. This can make the client feel unheard and invalidated. Choice B demonstrates empathy and offers support by acknowledging the client's feelings and offering to sit with them. Choice C also shows empathy and provides an opportunity for the client to talk. Choice D is non-therapeutic as it jumps to suggesting medication without exploring the client's emotions or needs.
A nurse is performing an admission assessment on a client who has been diagnosed with schizophrenia. Which of the following findings should the nurse identify as a negative symptom?
- A. Bizarre behavior
- B. Waxy flexibility
- C. Somatic delusions
- D. Illogicality
Correct Answer: B
Rationale: Waxy flexibility reflects a lack of normal movement a negative symptom of schizophrenia.