Nokea
The 84-year-old female client is admitted with multiple burn marks on the torso and under the breasts along with contusions in various stages of healing. When questioned by the nurse, the woman denies any problems have occurred. The woman lives with her son and does the housework. Which is the most probable reason the woman denies being abused?
- A. There has not been any abuse to report.
- B. The client is ashamed to admit being abused.
- C. The client has Alzheimer’s disease and can’t remember.
- D. The client has engaged in consensual sex.
Correct Answer: B
Rationale: Shame often leads elderly abuse victims to deny abuse, especially when dependent on the abuser (e.g., son). Lack of abuse is unlikely given findings, Alzheimer’s is speculative, and sex is unrelated.
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The nurse is teaching a class on bioterrorism. Which statement is the scientific rationale for designating a specific area for decontamination?
- A. Showers and privacy can be provided to the client in this area.
- B. This area isolates the clients who have been exposed to the agent.
- C. It provides a centralized area for stocking the needed supplies.
- D. It prevents secondary contamination to the health-care providers.
Correct Answer: D
Rationale: Decontamination areas prevent secondary contamination to HCPs, the primary rationale. Privacy, isolation, and supply stocking are secondary benefits.
The nurse working in an outpatient clinic is caring for a client who is experiencing epistaxis. Which intervention should the nurse implement first?
- A. Take the client’s blood pressure in both arms.
- B. Hold the nose with thumb and finger for 15 minutes.
- C. Have the client sit with the head tilted back and hold a tissue.
- D. Prepare to administer silver nitrate, a cauterizing agent, with a packing applicator.
Correct Answer: B
Rationale: Holding the nose for 15 minutes stops bleeding, the first intervention for epistaxis. BP, head tilting back (risks aspiration), and cauterization are secondary.
Which statement best describes the role of the medical-surgical nurse during a disaster?
- A. The nurse may be assigned to ride in the ambulance.
- B. The nurse may be assigned as a first assistant in the operating room.
- C. The nurse may be assigned to crowd control.
- D. The nurse may be assigned to the emergency department.
Correct Answer: D
Rationale: Medical-surgical nurses are often reassigned to the ED during disasters to manage increased patient loads. Ambulance, OR, and crowd control roles are less typical.
The client has been brought to the ED by ambulance following a motor-vehicle accident with a flail chest, an intravenous line, and a Heimlich valve. Which intervention should the nurse implement first?
- A. Start a large-bore intravenous access.
- B. Request a portable chest x-ray.
- C. Prepare to insert chest tubes.
- D. Assess the cardiac rhythm on the monitor.
Correct Answer: C
Rationale: A flail chest with a Heimlich valve indicates a pneumothorax; preparing for chest tube insertion stabilizes breathing, the priority. Additional IVs, x-rays, and cardiac monitoring follow.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical unit. Which nursing task cannot be delegated to the UAP?
- A. Obtaining the intake and output on a client diagnosed with food poisoning.
- B. Performing a dressing change on the client with a chemical burn.
- C. Assisting a client who overdosed on morphine to the bedside commode.
- D. Help a client with carbon monoxide poisoning turn, cough, and deep breathe.
Correct Answer: B
Rationale: Dressing changes on chemical burns require assessment and sterile technique, a nursing task. Intake/output, ambulation, and turning are delegable to UAPs.