Nokea
The home health nurse is providing long-term care to several clients. Which are examples of inappropriately crossing professional boundaries? Select all that apply.
- A. Accepting a birthday gift of a gold bracelet from a client
- B. Offering to pray together if a client so wishes
- C. Sending a sympathy card to family after a client dies
- D. Soliciting a wealthy client to invest in a company
- E. Staying after work hours and drinking wine with a client
Correct Answer: A,D,E
Rationale: Accepting expensive gifts (A), soliciting investments (D), and socializing with alcohol (E) violate professional boundaries. Offering to pray (B) is acceptable if client-initiated, and a sympathy card (C) is appropriate.
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The school nurse is conducting an educational session for middle school teachers that is designed to heighten awareness of school bullying. The nurse recognizes that further instruction is needed when one of the teachers makes which comment?
- A. Bullying is a normal part of childhood growth and development.
- B. Children with physical disabilities are more vulnerable to bullying.
- C. Most children who are victims of a school bully do not tell an adult about it.
- D. The most common form of bullying is verbal aggression, such as insults and intimidation.
Correct Answer: A
Rationale: Bullying is not a normal part of development (A) and requires intervention. Vulnerability of disabled children (B), underreporting (C), and verbal aggression (D) are accurate.
The nurse is observing a staff member talking with the parent of a pediatric client. The parent is crying and states, 'I do not know what to do about this situation with my child.' The staff member responds, 'I am sure you will do the right thing.' The nurse should recognize that the staff member's response
- A. expresses interest in the parent's concern
- B. demonstrates respect for the parent's privacy
- C. devalues the parent's feelings and gives false reassurance
- D. conveys empathy toward the parent and promotes self-confidence
Correct Answer: C
Rationale: The response (C) dismisses the parent's distress and provides false reassurance, lacking empathy. It does not express interest (A), respect privacy (B), or convey empathy (D).
A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts on death and dying at this age?
- A. Death is personified as the bogeyman or devil
- B. Death is perceived as being irreversible
- C. The child feels guilty for the grandmother's death
- D. The child is worried that he, too, might die
Correct Answer: A
Rationale: Death is personified as the bogeyman or devil. Personification of death is typical of this developmental level.
The nurse monitoring a client with appendicitis will expect the client to give which description of the associated abdominal pain?
- A. A burning sensation; in the upper abdomen
- B. An 8 out of 10; on the left side below the belly button
- C. Excruciating; in the lower abdomen above the right hip
- D. Intermittent; in the abdomen and right shoulder
Correct Answer: C
Rationale: Appendicitis typically causes severe pain in the right lower quadrant (C). Upper abdominal burning (A) suggests gastritis, left-sided pain (B) is atypical, and shoulder pain (D) may indicate referred pain from other conditions.
The nurse is reinforcing education about home care to the parent of a 10-year-old with cystic fibrosis. Which of the following statements by the parent indicates that teaching has been effective? Select all that apply.
- A. Chest physiotherapy is administered only if respiratory symptoms worsen.
- B. I will give my child pancreatic enzymes with all meals and snacks.
- C. I will increase my child's salt intake during hot weather.
- D. Our child will need a high-carbohydrate, high-protein diet.
- E. We will limit our child's participation in sports activities.
Correct Answer: B,C,D
Rationale: Pancreatic enzymes with meals (B), increased salt in hot weather (C), and a high-calorie, high-protein diet (D) are correct for cystic fibrosis management. Chest physiotherapy (A) is routine, not symptom-based, and limiting sports (E) is unnecessary unless advised.