Nokea
Ten-year-old Jackie is admitted to the hospital with a medical diagnosis of Rheumatic Fever. She relates a history of 'a sore throat about a month ago.' Bed rest with bathroom privileges is prescribed. Which of the following nursing assessments should be given the highest priority when assessing Jackie's condition?
- A. her response to being hospitalized
- B. the presence of a macular rash on her trunk
- C. her cardiac status
- D. the presence of polyarthritis and pain in her joints
Correct Answer: C
Rationale: Monitoring cardiac status is of the highest priority. Permanent cardiac damage can result from rheumatic fever. The second priority is assessing the client's joints for the presence of polyarthritis and accompanying pain.
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Two staff nurses were considered for promotion to head nurse. The promotion is announced via a memo on the unit bulletin board. The nurse who was not promoted tells a friend, 'Oh, well, I really didn't want the job anyway.' This is an example of:
- A. rationalization.
- B. denial.
- C. projection.
- D. compensation.
Correct Answer: A
Rationale: This is called the sour grapes form of rationalization. Rationalization is an unconscious form of self-deception in which excuses are made.
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.
A 12-year-old male is brought to his primary care provider to determine whether sexual abuse has occurred. The mother states, 'Because there is no permanent physical damage, he does not need any more treatment.' The nurse's response should be based on which of the following pieces of information?
- A. Male victims of sexual abuse seldom have long-term psychological problems.
- B. Survivors of male sexual abuse might become confused about their sexual identity.
- C. Unless treated, all male sex abuse survivors grow up to abuse other children.
- D. All children who have been sexually abused have the same needs, regardless of gender.
Correct Answer: B
Rationale: Male children are sexually abused nearly as often as female children. Perpetrators are usually men but can be women. Needs of male children who have been sexually abused might be different from the needs of female survivors. Male survivors might respond in anger, question their sexuality, use alcohol and other drugs, and might try to prove their masculinity by performing daring acts.
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.
The nurse is working with families who have been displaced by a fire in an apartment complex. What is the priority intervention during the initial assessment?
- A. Provide a liaison to meet housing needs.
- B. Attentively listen when clients describe their feelings.
- C. Offer nurturing support for clients who are confused by the events.
- D. Provide structure for clients exhibiting moderate to severe anxiety.
Correct Answer: A
Rationale: After physical needs of housing, clothing and food are met, the nurse should focus on assisting clients to manage the psychological effects of loss.