Nokea
The client with schizophrenia has become disruptive and requires seclusion. Which staff member can institute seclusion?
- A. The security guard
- B. The registered nurse
- C. The licensed practical nurse
- D. The nursing assistant
Correct Answer: B
Rationale: The registered nurse is the correct choice to institute seclusion for a client with schizophrenia. In healthcare settings, only a registered nurse or a physician can legally initiate seclusion. The security guard, licensed practical nurse, and nursing assistant do not have the authority to carry out this action. Therefore, options A, C, and D are incorrect.
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A client with cancer develops xerostomia. The nurse can help alleviate the discomfort associated with xerostomia by:
- A. Offering hard candy
- B. Administering analgesic medications
- C. Splinting swollen joints
- D. Providing saliva substitute
Correct Answer: D
Rationale: Xerostomia is dry mouth, a common side effect in cancer patients. Providing a saliva substitute helps alleviate the discomfort associated with dry mouth by moistening the oral mucosa. Offering hard candy, as mentioned in choice A, can worsen xerostomia by increasing sugar content and potentially causing irritation. Administering analgesic medications, as in choice B, is not directly related to treating dry mouth. Splinting swollen joints, as in choice C, is irrelevant to xerostomia, which primarily affects the oral cavity.
Which laboratory test would be the least effective in diagnosing a myocardial infarction?
- A. AST
- B. Troponin
- C. CK-MB
- D. Myoglobin
Correct Answer: A
Rationale: AST, choice A, would be the least effective in diagnosing a myocardial infarction as it is not specific for this condition. Troponin, CK-MB, and myoglobin (choices B, C, and D) are more specific markers for myocardial infarction. Troponin is considered the gold standard due to its cardiac specificity. CK-MB is also specific to the heart, and its isoenzyme levels elevate post-heart damage. Myoglobin, although elevated in myocardial infarction, is not as specific as troponin and CK-MB and can also increase in conditions like burns and muscle trauma. Therefore, AST is the least effective choice for diagnosing a myocardial infarction.
The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:
- A. Grimacing and writhing movements decrease with relaxation and rest.
- B. Hypoactive deep tendon reflexes become more active with rest.
- C. Stretch reflexes are increased with rest.
- D. Fine motor movements are improved.
Correct Answer: A
Rationale: Frequent rest periods help to relax tense muscles and preserve energy in clients with cerebral palsy. This can lead to a decrease in grimacing and writhing movements, as relaxation and rest help to alleviate muscle tension. Choices B, C, and D are incorrect because they provide inaccurate information. Hypoactive deep tendon reflexes do not become more active with rest; stretch reflexes are not increased with rest in cerebral palsy patients, and fine motor movements are not necessarily improved solely by rest.
In which age group does the highest incidence of child abuse occur?
- A. Birth-3 years old
- B. 4-6 years old
- C. 6-10 years old
- D. More than 10 years old
Correct Answer: A
Rationale: The correct answer is 'Birth-3 years old.' Children between birth and 3 years of age have the highest rates of victimization (at 16 per 1,000 children). This age group is most vulnerable due to their dependency and inability to report or protect themselves effectively. Child abuse can occur at any age, but statistics show that infants and toddlers are at the highest risk due to their developmental stage and reliance on caregivers. Choices B, C, and D are incorrect because while child abuse can happen at any age, the prevalence is highest among children in the 0-3 age group.
Which of the following statements is correct regarding rape?
- A. Most rapes go unreported.
- B. Legally, a woman can be raped by her spouse.
- C. Prosecuting and convicting for rape can be challenging.
- D. Rape can occur in different locations.
Correct Answer: B
Rationale: The correct statement is that legally, a woman can be raped by her spouse. Rape is defined as sexual intercourse against someone's will, and it can occur between any two persons regardless of their relationship, including spouses. Choice A is incorrect as most rapes are not reported due to various reasons like fear, shame, or distrust in the legal system. Choice C is incorrect as prosecuting and convicting for rape can be challenging due to factors like lack of evidence, societal biases, and victim blaming. Choice D is incorrect as the most common location of rape is not necessarily the victim's own home; it can happen in various settings such as public places, workplaces, or social gatherings.