Nokea
In an interview for suspected child abuse, the child's mother openly discusses her feelings. She feels her husband is too aggressive in disciplining their child. The child's father states, 'Being a school custodian, I see kids every day that are bad because they did not get enough discipline at home. That will not happen to our child.' Based on this remark, the nurse would make the following nursing diagnosis:
- A. Fear related to retaliation by the father
- B. Actual injury related to poor impulse control by the father
- C. Ineffective coping
- D. Altered family process related to physical abuse
Correct Answer: D
Rationale: There is no evidence of fear as the child is unable to communicate. There is actual injury, but the parents have not yet admitted causing the child's injuries. This diagnosis is incomplete. There is no specific ineffective coping behavior identified in this nursing diagnosis. Altered family process best describes the family dynamics in this situation. The parents have admitted severe disciplinary action.
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A baby is circumcised. Immediate postoperative care should include:
- A. Applying a loose diaper
- B. Keeping the baby NPO for 4 hours to avoid vomiting
- C. Changing the dressing frequently using dry, sterile gauze
- D. Taking the baby to his mother for cuddling
Correct Answer: D
Rationale: A pressure diaper should be applied to discourage hemorrhage. The baby can be fed by his mother soon after the procedure, once it is assessed that he is not in any distress and is stable. Dressing changes should not be dry. Dry dressing will stick. Cuddling after the procedure will hopefully quiet the baby. Feeding is also important if his feeding was withheld prior to the procedure or it is time for a feeding.
Which of the following describes a positive Kernig's sign?
- A. Pain on flexion of the hip and knee
- B. Nuchal rigidity on flexion of the neck
- C. Pain when the head is turned to the left side
- D. Dizziness when changing positions
Correct Answer: A
Rationale: A positive Kernig’s sign is pain or resistance when flexing the hip and extending the knee often indicating meningeal irritation (e.g. meningitis). The other options describe different symptoms or signs unrelated to Kernig’s.
A client is admitted with suspected Hodgkin's lymphoma. The diagnosis is confirmed by the:
- A. Overproliferation of immature white cells
- B. Presence of Reed-Sternberg cells
- C. Increased incidence of microcytosis
- D. Reduction in the number of platelets
Correct Answer: B
Rationale: Hodgkin's lymphoma is diagnosed by the presence of Reed-Sternberg cells in lymph node biopsy, a hallmark of the disease.
The client is diagnosed with multiple myeloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client?
- A. Walk about a mile a day to prevent calcium loss.'
- B. Increase the fiber in your diet.'
- C. Report nausea to the doctor immediately.'
- D. Drink at least eight large glasses of water a day.'
Correct Answer: D
Rationale: Cyclophosphamide can cause hemorrhagic cystitis, so adequate hydration (e.g., 8 glasses of water daily) is essential to flush the bladder and reduce this risk. Walking, fiber, and nausea reporting are not primary concerns with this drug.
The client with a history of epilepsy is prescribed valproic acid (Depakote). Which laboratory test should the nurse monitor?
- A. Liver function tests
- B. Renal function tests
- C. Complete blood count
- D. Electrolytes
Correct Answer: A
Rationale: Valproic acid can cause hepatotoxicity, so liver function tests (e.g., AST, ALT) are monitored regularly. Renal function, blood counts, and electrolytes are less commonly affected.