Nokea
The nurse contributed to a staff education program about transmission precautions to use when caring for a patient who has AIDS. Which statement by a staff member indicates a correct understanding of the teaching?
- A. Wear a mask for any patient contact.'
- B. Wear a waterproof gown at all times.'
- C. Wear clean gloves for body fluid contact.'
- D. Wear sterile gloves for any patient contact.'
Correct Answer: C
Rationale: The correct answer is C: "Wear clean gloves for body fluid contact." This is correct because wearing clean gloves when coming into contact with body fluids is essential to prevent the transmission of infections like AIDS. Sterile gloves are not necessary for routine patient care, and wearing a mask or waterproof gown is not indicated unless there is a specific risk of droplet or airborne transmission. Thus, the staff member demonstrating an understanding of using clean gloves for body fluid contact shows knowledge of proper transmission precautions for caring for a patient with AIDS.
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The best way to objectively evaluate the effectiveness of an individual staff member's time management skills in a longitudinal manner is to:
- A. Observe the staff member during an entire shift of duty to determine whether or not the nurse has accurately and appropriately established priorities.
- B. Observe the staff member during an entire shift of duty to determine whether or not the nurse has accurately and appropriately completed priority tasks.
- C. Ask the staff member how they feel like they have been able to employ their time management skills for the last six months.
- D. Collect outcome data over time and then aggregate and analyze this data to determine whether or not the staff member has completed reasonable assignments in the allotted time before the end of their shift of duty.
Correct Answer: D
Rationale: Longitudinal evaluation requires data collection and analysis over time.
Which question best assesses an individual's ability to cope with the potential emotional crisis resulting from the death of a parent?
- A. Have you ever lost a loved one before?'
- B. Do you think you will be able to cope well?'
- C. Do you feel you have supportive people to rely upon?'
- D. Are you able to draw on fond memories of your parent?'
Correct Answer: A
Rationale: The correct answer is A, "Have you ever lost a loved one before?" This question assesses the individual's prior experience with loss, providing insight into their coping mechanisms. It allows the individual to reflect on past experiences and potentially apply strategies used previously. Choice B is too direct and may not accurately predict coping ability. Choice C focuses on external support rather than individual coping skills. Choice D assumes positive memories are always accessible, which may not be the case in grief.
Which assessment findings support a nurse’s suspicion that a patient has been using inhalants?
- A. Perforated nasal septum and hypertension
- B. Drowsiness, euphoria, and constipation
- C. Pinpoint pupils and respiratory rate of 12 breaths per minute
- D. Confusion, mouth ulcers, and ataxia
Correct Answer: D
Rationale: The correct answer is D because confusion, mouth ulcers, and ataxia are common assessment findings in individuals who have been using inhalants. Confusion and ataxia are neurological symptoms associated with inhalant use, while mouth ulcers can result from the toxic effects of inhalants on oral mucosa. These findings indicate central nervous system depression and potential damage from inhalant exposure.
Choices A, B, and C are incorrect because they do not align with typical assessment findings of inhalant use. Perforated nasal septum and hypertension (A) are more commonly associated with chronic cocaine use. Drowsiness, euphoria, and constipation (B) are symptoms of opioid use. Pinpoint pupils and respiratory rate of 12 breaths per minute (C) are indicative of opioid overdose, not inhalant use.
A patient admitted to an alcoholism rehabilitation program says, 'I’m just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening.' Which defense mechanism is evident?
- A. Rationalization
- B. Introjection
- C. Projection
- D. Denial
Correct Answer: D
Rationale: The correct answer is D: Denial. The patient's statement reflects denial as they are minimizing their alcohol consumption by categorizing it as normal social drinking. Denial is a defense mechanism where a person refuses to acknowledge a reality or truth to protect themselves from anxiety or discomfort. In this scenario, the patient is not accepting the reality of their excessive drinking habits.
Explanation for other choices:
A: Rationalization - This defense mechanism involves justifying behavior with logical reasoning. The patient is not providing logical reasoning for their drinking habits.
B: Introjection - This defense mechanism involves internalizing external beliefs or values. The patient's statement does not indicate internalizing external beliefs.
C: Projection - This defense mechanism involves attributing one's unacceptable thoughts or emotions to others. The patient is not projecting their drinking habits onto others.
The nurse is conducting a family assessment. When asked about her children's performance at school, the single mother reported that her oldest, a 10-year-old, 'does OK with schoolwork but doesn't have any interest in being friends with the kids in her school.' To further investigate this situation the nurse asks the:
- A. Child why she doesn't have friends at school.
- B. Mother if her younger children have friends at school.
- C. Child what she does at home after she comes home from school.
- D. Mother to discuss the situation with the child's teacher or school counselor.
Correct Answer: C
Rationale: The correct answer is C because asking the child what she does at home after school can provide insights into her social interactions, interests, and possible reasons for not having friends at school. This approach allows the nurse to understand the child's daily routine, activities, and possible areas for intervention or support.
A: Asking the child directly why she doesn't have friends may not yield accurate information as the child may not be able to articulate her feelings or may not be comfortable discussing the issue openly.
B: Inquiring about the younger children's friendships is not relevant to understanding the oldest child's situation and may not provide meaningful insights.
D: Involving the teacher or counselor without understanding the child's perspective first may not address the underlying reasons for her lack of friends and may not be the most appropriate initial step in the assessment process.