Nokea
Support-system enhancement includes all of the following except:
- A. determining the barriers to using support systems.
- B. discussing ways to help with others who are concerned.
- C. exploring life problems of the support-team members.
- D. involving spouse, family, and friends in the care and planning.
Correct Answer: C
Rationale: The exploration of life problems of support-team members is not necessary to enhance the support system. Choices 1, 2, and 4 are all enhancements for a support system.
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An 8-year-old Asian child is being examined during a school screening. The nurse notices small bruises on the anterior and posterior ribs. The nurse should ask the child:
- A. If the family practices coining
- B. Who hit him
- C. If the child has fallen
- D. How long the abuse has been occurring
Correct Answer: A
Rationale: Coining, a cultural practice in some Asian communities, can cause bruising and should be assessed to differentiate from abuse. Other options assume abuse prematurely.
The nurse is assessing an elder who the nurse suspects is being physically abused. The most important question for nurse to ask is:
- A. How much money do you keep around the house?
- B. Who provides your physical care?
- C. How close does your nearest relative live?
- D. What form of transportation do you use?
Correct Answer: B
Rationale: The most common abuser is a caregiver living with the client. Research reveals that the spouse is currently the most common abuser, followed by an adult child.
The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?
- A. How did you get those bruises?'
- B. Did someone grab you by your arms?'
- C. Do you fall often?'
- D. What did you bump against?'
Correct Answer: B
Rationale: Using a direct approach is best when asking about suspected abuse. Clients are reluctant to report abuse because of shame and fear of reprisal.
Appropriate nursing strategies to assist a client in maintaining a sense of self include:
- A. using the client's first name when addressing the client
- B. treating the client with dignity
- C. explaining procedures only if the client is attentive
- D. discouraging the use of personal items
Correct Answer: B
Rationale: Treating the client with dignity respects their individuality and fosters a sense of self, unlike the other options, which may undermine autonomy or engagement.
Support systems during the grieving process include all of the following except:
- A. a despondent friend.
- B. a nurse.
- C. a social worker.
- D. a family member.
Correct Answer: A
Rationale: A despondent friend, even though this could be a support to the grieving person, is in a state of despondency. Therefore, he or she might not do well with a grieving friend.