Nokea
During the admission interview, an adult client reveals that, as a child, she was sexually abused by her uncle and a male cousin. She reports that she cuts the skin of her arms, legs, and abdomen. In addition to having the client sign a no-harm contract, which nursing intervention is most important?
- A. Assist the client with finding safe ways to express her anger.
- B. Talk with the client about confronting her uncle and cousin directly.
- C. Defer talking about the abuse to prevent further self-mutilation.
- D. Discuss the possibility of the client suing her relatives for their abuse.
Correct Answer: A
Rationale: Helping the client find safe ways to express anger addresses the self-harm behavior therapeutically, promoting coping skills and safety.
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The home care nurse is doing an assessment interview with an older adult client who asks the nurse to buy some groceries for her because she is not feeling well today. Which statement should the nurse use in response?
- A. Do you often need help with food shopping?
- B. Let's discuss how we can solve this problem.
- C. Do you have any support systems for shopping?
- D. I wish I could but I don't have time to run errands.
Correct Answer: B
Rationale: The nurse's duty is to help the client; but in helping the client, the nurse's first action is to finish the assessment and then find immediate and long-term solutions to the problem. In options 1 and 3 the nurse asks a closed-ended question, which is unlikely to further nurse-client communication. Option 4 is inappropriate while failing to address the client's problem.
Place the following steps for mixing NPH and regular insulin in the proper sequential order from # 1 to # 6 below. #1 - Prep the top of the shorter acting insulin with an alcohol swab #2 - Inject air that is equal to the ordered dosage of the shorter acting insulin using the same insulin syringe. #3 - Withdraw the ordered dosage of the shorter acting insulin using the same insulin syringe. #4 - Prep the top of the longer acting insulin vial with an alcohol swab. #5 - Inject air that is equal to the ordered dosage of the longer acting insulin using the insulin syringe. #6 - Withdraw the ordered dosage of the longer acting insulin using the same insulin syringe.
- A. 1,5,4,2,3,6
- B. 4,3,2,6, 1,5
- C. 4,2,5,3, 1,6
- D. 1,5,3,6,4,2
Correct Answer: A
Rationale: The correct sequence is: 1) Prep short-acting insulin vial, 2) Inject air into short-acting vial, 3) Withdraw short-acting insulin, 4) Prep long-acting insulin vial, 5) Inject air into long-acting vial, 6) Withdraw long-acting insulin to avoid contamination.
A client receiving a blood transfusion begins to have chills and headache within the first 15 minutes of the transfusion. The nurse should first:
- A. Administer acetaminophen.
- B. Take the client's blood pressure.
- C. Discontinue the transfusion.
- D. Check the infusion rate of the blood.
Correct Answer: C
Rationale: Chills and headache suggest a transfusion reaction, requiring immediate discontinuation of the transfusion to prevent further complications.
The nurse assesses a 7-month-old infant's growth and development. Which behavior should the nurse consider unusual?
- A. Drinking from a cup and spilling little of the liquid.
- B. Raising the chest and upper abdomen off the bed with the hands.
- C. Imitating sounds that the nurse makes.
- D. Crying loudly in protest when the mother leaves the room.
Correct Answer: A
Rationale: Drinking from a cup with minimal spilling is advanced for a 7-month-old, who typically lacks such fine motor control.
Your client has a tube feeding. Which of the following commonly occurring complications of tube feedings can you prevent with the preventive measure that is coupled with it?
- A. Constipation: The provision of a high fiber diet
- B. Urinary pH changes: Encouraging ample oral fluid intake
- C. Aspiration: Maintaining the client in at least a 30 degree angle
- D. Aspiration: Maintaining the client in at least a 90 degree angle
Correct Answer: C
Rationale: Maintaining a 30-45 degree angle during tube feedings reduces the risk of aspiration by preventing reflux of gastric contents.