Nokea
The nurse has been caring for a 16-year-old female who recently experienced date rape. After having had crisis intervention and been hospitalized for 2 weeks, the nurse knows that the client is effectively coping with the rape when she tells the nurse:
- A. I know it was my fault that it happened, because I shouldn't have been out so late.'
- B. If I had not worn that sexy dress that night, he wouldn't have raped me.'
- C. I know my date just had so much passion he couldn't handle me saying 'no.'
- D. I know now that it was not my fault, but I want to continue counseling after my discharge.'
Correct Answer: D
Rationale: The client has insight into the rape; she does not believe it was her fault and shows good judgment in deciding to continue with counseling after discharge.
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A female client has been treated since childhood for mitral valve prolapse. The antibiotic of choice for her during pregnancy would be:
- A. Sulfa
- B. Tetracycline
- C. Hydralazine
- D. Erythromycin
Correct Answer: D
Rationale: Sulfa is a teratogen and will cause kernicterus. Tetracycline is a teratogen and will affect tooth development. Hydralazine is not an antibiotic but a calcium channel blocker. Erythromycin is safe during pregnancy and can be used when the client is allergic to penicillin.
A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal, full-term girl and is now progressing toward the establishment of successful lactation. To remove the baby from her breast, she should be instructed to:
- A. Gently pull the infant away
- B. Withdraw the breast from the infant's mouth
- C. Compress the areolar tissue until the infant drops the nipple from her mouth
- D. Insert a clean finger into the baby's mouth beside the nipple
Correct Answer: D
Rationale: Inserting a finger into the infant's mouth breaks suction, allowing nipple removal without trauma. Other methods risk nipple injury.
The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching?
- A. I will have blood drawn every month.'
- B. I will assess my skin for a rash.'
- C. I take aspirin for a headache.'
- D. I will use an electric razor to shave.'
Correct Answer: C
Rationale: Taking aspirin while on warfarin increases bleeding risk due to their combined anticoagulant effects. The client needs further teaching to avoid aspirin. Monthly blood draws (for INR), checking for rashes (a side effect), and using an electric razor (to reduce cuts) are appropriate.
A 67-year-old man had a physical examination prior to beginning volunteer work at the hospital. A routine chest x-ray demonstrated left ventricular hypertrophy. His blood pressure was 180/110. He is 45 lb overweight. His diet is high in sodium and fat. He has a strong family history of hypertension. The client is placed on antihypertensive medication; a low-sodium, low-fat diet; and an exercise regimen. On his next visit, compliance would best be determined by:
- A. A blood pressure reading of 130/70 with a 5-lb weight loss
- B. No side effects from antihypertensive medication and an accurate pill count
- C. No evidence of increased left ventricular hypertrophy on chest x-ray
- D. Serum blood levels of the antihypertensive medication within therapeutic range
Correct Answer: A
Rationale: A blood pressure within acceptable range best demonstrates compliance, but weight loss cannot be accomplished without adherence to medication, diet, and exercise. Absence of side effects does not indicate compliance with medication. Pill counts can be misleading because the client can alter pill counts prior to visit. Left ventricular hypertrophy is not an accurate measure of compliance because hypertrophy frequently does not decrease even with pharmacological management. Therapeutic blood levels measure the drug level at the time of the test. There is no indication of compliance several days before testing.
Which measure helps reduce nipple soreness associated with breastfeeding?
- A. Feeding the baby during the first 48 hours after delivery
- B. Placing a finger between the baby's mouth and the breast to break suction after feeding
- C. Applying warm, moist soaks to the breast several times per day
- D. Wearing a support bra during the day
Correct Answer: B
Rationale: Breaking suction by placing a finger between the baby’s mouth and the breast prevents trauma to the nipple, reducing soreness. Feeding early promotes latch but doesn’t address soreness directly, warm soaks may increase inflammation, and a bra supports but doesn’t prevent nipple trauma.