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During a health assessment, a nurse is assisting with gathering subjective data from a client and plans to ask the client about the medical history of the client's extended family. About which family members would the nurse ask the client?
- A. Aunts, uncles, grandparents, and cousins
- B. Foster children and their parents
- C. Wife's children from a previous marriage
- D. Wife and wife's parents
Correct Answer: B
Rationale: The correct answer is 'Aunts, uncles, grandparents, and cousins.' When gathering medical history from the client's extended family, it is essential to inquire about relatives beyond the nuclear family, such as aunts, uncles, grandparents, and cousins, as they share genetic and environmental influences. Choice C, 'Wife's children from a previous marriage,' pertains to stepchildren, not extended family members. Choice B, 'Foster children and their parents,' involves individuals who are not biologically related to the client's family. Choice D, 'Wife and wife's parents,' focuses solely on immediate family members and excludes the client's extended family members, which are crucial for a comprehensive health assessment.
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The nurse notes that a client in later adulthood has tremors of the hands. Based on this finding, what action should the nurse take?
- A. Ask the healthcare provider about referring the client to a neurological specialist.
- B. Obtain a prescription for a muscle relaxant.
- C. Notify the healthcare provider immediately.
- D. Document the findings.
Correct Answer: D
Rationale: When a nurse observes senile tremors, such as intentional tremor of the hands in a client in later adulthood, it is important to document the findings. Senile tremors are benign and a normal age-related occurrence. Referring the client to a neurological specialist (Choice A) is unnecessary as senile tremors do not require specialized neurological intervention. Prescribing a muscle relaxant (Choice B) is not indicated since senile tremors are benign and not typically treated with muscle relaxants. Notifying the healthcare provider immediately (Choice C) is unnecessary as senile tremors do not require urgent intervention. Therefore, the most appropriate action is to document the findings (Choice D) for the client's medical record and to establish a baseline for future assessments.
What effect can medication bound to protein have?
- A. reduced drug availability
- B. limited distribution of the drug to receptor sites
- C. less availability to produce desired medicinal effects
- D. decreased metabolism of the drug by the liver
Correct Answer: C
Rationale: Medication bound to protein leads to less availability to produce desired medicinal effects because only unbound drugs can interact with active receptor sites. If a drug is bound to protein, it cannot bind with a receptor site, reducing its effectiveness. Choice A is incorrect because binding to protein reduces drug availability. Choice B is incorrect because distribution to receptor sites is ineffective if the drug is bound to protein. Choice D is incorrect because metabolism does not occur until the drug is removed from the protein molecule by the liver, allowing the protein to return to circulation.
A female client asks a nurse about the advantages of using a female condom. The nurse discusses which advantage with the client?
- A. That it offers protection against sexually transmitted infections (STIs)
- B. That it cannot be used along with a male condom
- C. That it does not have to be discarded after use and can be used several times before a new one must be obtained
- D. That it is 100% effective in preventing pregnancy
Correct Answer: A
Rationale: The correct answer is that the female condom offers protection against sexually transmitted infections (STIs). Unlike the male condom, the female condom is a loose-fitting tubular polyurethane pouch that is anchored over the labia and cervix. It is used once and then discarded, making choice C incorrect. Female and male condoms should not be used together, so choice B is incorrect. Additionally, no contraceptive method is 100% effective in preventing pregnancy, making choice D incorrect.
When reviewing a client's medical notes to confirm pregnancy, a nurse should look for which finding to determine that pregnancy is confirmed?
- A. Amenorrhea
- B. Thinning of the cervix
- C. Palpable fetal movement
- D. Positive result on a home urine test for pregnancy
Correct Answer: C
Rationale: To confirm pregnancy, the presence of palpable fetal movement is a positive indicator. Palpable fetal movement is a certain sign of pregnancy, known as a fetal movement felt by the examiner. Amenorrhea is a presumptive sign of pregnancy as it is reported by the woman but is not confirmatory. Thinning of the cervix (Hegar sign) is a probable sign of pregnancy, which is not confirmatory. A positive result on a home urine test for pregnancy is also a probable indicator. However, a positive pregnancy test result can sometimes yield false-positive results due to various factors like medication, recent pregnancy, or errors in reading.
According to Erikson, which developmental task is a toddler confronting when they develop 'a will of his own' and 'acts as if he can control others'?
- A. Trust versus mistrust
- B. Autonomy versus doubt and shame
- C. Initiative versus guilt
- D. Industry versus inferiority
Correct Answer: B
Rationale: According to Erikson, the correct developmental task for a toddler who has developed 'a will of his own' and 'acts as if he can control others' is Autonomy versus doubt and shame. Toddlers at this stage are asserting their wills and realizing they can control others, which is part of developing autonomy. However, they may also experience doubt and shame if their assertiveness is met with disapproval. Trust versus mistrust is the developmental task of the infant, where the main focus is on developing trust in the caregiver. Initiative versus guilt is the developmental task of the preschool-age child, emphasizing the balance between taking initiative and feeling guilty. Industry versus inferiority is the developmental task of the school-age child, focusing on competence and self-esteem.