Nokea
During a school screening, a nurse notices small bruises on the anterior and posterior ribs of an 8-year-old Asian child. The nurse should ask the child:
- A. if the family practices coining
- B. who performs coinings
- C. if the child has fallen
- D. how long the child has been abused
Correct Answer: A
Rationale: The correct answer is to ask if the family practices coining. In Asian cultures, coining is a traditional practice believed to draw infections from the body. It involves rubbing a heated coin on the chest and torso, which can cause bruising similar to what the nurse noticed on the child's ribs. This question is important to differentiate between cultural practices and potential child abuse. Choices B, C, and D are incorrect because assuming abuse without considering cultural practices can lead to misinterpretation and inappropriate actions. It's crucial for healthcare providers to be culturally sensitive and gather all relevant information before making conclusions.
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Which of the following is not one of the three universal spiritual needs?
- A. meaning and purpose
- B. love and relatedness
- C. forgiveness
- D. God's permission
Correct Answer: D
Rationale: The three universal spiritual needs are meaning and purpose, love and relatedness, and forgiveness. These needs are commonly recognized across various belief systems and cultures. While the concept of God may be central to many religions, 'God's permission' is not considered a universal spiritual need. Seeking 'God's permission' is more specific to certain religious practices rather than a universally acknowledged spiritual need. Therefore, the correct answer is 'God's permission.' Choices A, B, and C are correct as they align with the generally accepted universal spiritual needs.
The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse?
- A. Notify the police department for investigation
- B. Report this behavior to the charge nurse
- C. Monitor the situation and document any suspicious activities
- D. Confront the patient care assistant immediately
Correct Answer: B
Rationale: The appropriate action for the registered nurse in this scenario is to report the behavior to the charge nurse. This allows for proper investigation and intervention. Inappropriate actions include notifying the police directly without following the chain of command (Choice A), monitoring without immediate action (Choice C), and confronting the assistant without involving a superior (Choice D). By reporting to the charge nurse, the situation is escalated appropriately within the healthcare setting, ensuring the well-being and safety of the client.
The client with diverticulosis is being assisted by the nurse in selecting appropriate foods. Which food should be avoided?
- A. Bran
- B. Fresh peaches
- C. Cucumber salad
- D. Yeast rolls
Correct Answer: C
Rationale: The food that should be avoided for a client with diverticulosis is Cucumber salad. Foods with seeds should be avoided as they can aggravate diverticulosis by causing irritation and inflammation in the diverticula. Choices A, B, and D are allowed and even beneficial. Bran cereal and fruit like fresh peaches can help prevent constipation, which is beneficial for individuals with diverticulosis. Yeast rolls are also acceptable unless the client has specific dietary restrictions related to yeast or gluten.
The client is admitted to the unit after a cholecystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
- A. The client is at risk for evisceration.
- B. The client will require frequent dressing changes.
- C. The straps provide support for drains that are inserted in the incision.
- D. No sutures or clips are used to secure the incision.
Correct Answer: B
Rationale: Montgomery straps are used to secure dressings that require frequent changes due to the large amount of drainage usually present after a cholecystectomy. They are also beneficial for clients allergic to various types of tape. Answer A is incorrect as the client is not at higher risk of evisceration. Answer C is incorrect because Montgomery straps are not used to support drains. Answer D is incorrect as sutures or clips are typically used to secure the incision after gallbladder surgery, not Montgomery straps.
The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?
- A. The graduate places the client in a supine position to read the manometer.
- B. The graduate turns the stop-cock to the off position from the IV fluid to the client.
- C. The graduate instructs the client to perform the Valsalva maneuver during the CVP reading.
- D. The graduate notes the level at the top of the meniscus.
Correct Answer: C
Rationale: The correct answer is C because the client should breathe normally during a central venous pressure monitor reading. Placing the client in a supine position (Choice A) is correct if the client can tolerate it. Turning the stop-cock off (Choice B) and noting the level at the top of the meniscus (Choice D) are also correct actions during CVP monitoring. Instructing the client to perform the Valsalva maneuver is incorrect as it can artificially alter the CVP reading, indicating a need for further teaching.