Social support systems include of the following except:
- A. call-in help lines.
- B. emotional assistance provided by others.
- C. community support groups.
- D. use of coping skills and verbalization for anger management.
Correct Answer: D
Rationale: Use of coping skills and verbalization for anger management are personal strategies, not examples of social support systems. Choices 1, 2, and 3 are all social support systems.
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Which of the following diseases places a client at risk for developing cirrhosis?
- A. type I diabetes
- B. alcoholism
- C. leukemia
- D. glaucoma
Correct Answer: B
Rationale: Alcoholism places a client at risk for developing cirrhosis. None of the other choices are related to cirrhosis.
In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client's:
- A. feelings about what has been described
- B. thoughts about what has been described
- C. possible solutions to the problem
- D. intent in sharing the description
Correct Answer: B
Rationale: Eliciting the client's thoughts after describing issues provides insight into their perspective and interpretation, guiding further assessment. Feelings and solutions come later.
A client receiving preoperative instructions asks questions repeatedly about when to stop eating the night before the procedure. The nurse tries to refocus the client. The nurse notes that the client is frequently startled by noises in the hall. Assessment reveals rapid speech, trembling hands, tachypnea, tachycardia, and elevated blood pressure. The client admits to feeling nervous and having trouble sleeping. Based on the assessment, the nurse documents that the client has:
- A. mild anxiety.
- B. moderate anxiety.
- C. severe anxiety.
- D. a panic attack.
Correct Answer: C
Rationale: In severe anxiety, a client focuses on small or scattered details. The person is unable to solve problems. With mild anxiety, stimuli are readily perceived and processed, and the ability to learn and solve problems is enhanced. Moderate anxiety narrows the perceptual field, but the client notices things brought to his attention. During a panic attack, the person is disorganized and might be hyperactive or unable to speak or act.
A nurse notes that an elderly client suddenly does not keep appointments and is not wearing appropriate clothing. Which statement by the client raises the suspicion of financial abuse?
- A. I am having difficulty paying for this new antibiotic the physician prescribed.
- B. I am a little short on cash since my daughter moved in to help me.
- C. I have not felt like shopping since the weather has gotten worse.
- D. People do not realize how difficult it is to make ends meet on a fixed income.
Correct Answer: B
Rationale: Signs of financial abuse include an inability to pay for necessities like clothes, and the statement about being short on cash since the daughter moved in suggests possible misuse of funds by a caregiver.
When assessing a client in the Emergency Department whose membranes have ruptured, the nurse notes that the fluid is a greenish color. What is the cause of this greenish coloration?
- A. blood
- B. meconium
- C. hydramnios
- D. caput
Correct Answer: B
Rationale: Greenish amniotic fluid passed when the fetus is in a cephalic (head) presentation might indicate fetal distress. A fetus in the breech presentation passes meconium due to compression on the intestinal tract.