Nokea
The nurse in an outpatient rehabilitation facility is working with convicted child abusers. Which characteristics should the nurse expect to observe in the abusers? Select all that apply.
- A. The abuser calls the child a liar.
- B. The abuser has a tendency toward violence.
- C. The abuser exhibits a high self-esteem.
- D. The abuser is unable to admit the need for help.
- E. The abuser was spoiled as a child.
Correct Answer: A,B,D
Rationale: Child abusers often deny accusations (calling the child a liar), exhibit violence, and resist help due to denial. Low self-esteem is more common, and being spoiled is not typical.
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The nurse caring for a client with sepsis writes the client diagnosis of 'alteration in comfort R/T chills and fever.' Which intervention should be included in the plan of care?
- A. Ambulate the client in the hallway every shift.
- B. Monitor urinalysis, creatinine level, and BUN level.
- C. Apply sequential compression devices to the lower extremities.
- D. Administer an antipyretic medication every four (4) hours PRN.
Correct Answer: D
Rationale: Antipyretics (e.g., acetaminophen) address fever and chills, improving comfort. Ambulation, lab monitoring, and compression devices address other sepsis concerns, not comfort.
Which situation requires the emergency department manager to schedule and conduct a Critical Incident Stress Management (CISM)?
- A. Caring for a two (2)-year-old child who died from severe physical abuse.
- B. Performing CPR on a middle-aged male executive who died.
- C. Responding to a 22-victim bus accident with no apparent fatalities.
- D. Being required to work 16 hours without taking a break.
Correct Answer: A
Rationale: CISM addresses emotional trauma, critical for staff after a child’s death from abuse. CPR death is routine, bus accidents without fatalities are less traumatic, and long hours are logistical.
Which signs/symptoms should the nurse assess in the client who has been exposed to the anthrax bacillus via the skin?
- A. A scabby, clear fluid-filled vesicle.
- B. Edema, pruritus, and a 2-mm ulcerated vesicle.
- C. Irregular brownish-pink spots around the hairline.
- D. Tiny purple spots flush with the surface of the skin.
Correct Answer: B
Rationale: Cutaneous anthrax presents with edema, pruritus, and a small ulcerated vesicle that becomes necrotic. Scabby vesicles, brownish-pink spots, and purple spots are not typical.
The client has ingested the remaining amount of a bottle of analgesic medication. The medication comes 500 mg per capsule. Two (2) doses of two (2) capsules each have been used by another member of the family. The bottle originally had 250 capsules. How many mg of medication did the client take?
Correct Answer: 123000
Rationale: Total capsules: 250. Used: 2 doses * 2 capsules = 4 capsules. Remaining: 250 - 4 = 246 capsules. Total mg: 246 * 500 mg = 123,000 mg.
The father of a child brought to the emergency department is yelling at the staff and obviously intoxicated. Which approach should the nurse take with the father?
- A. Talk to the father in a calm and low voice.
- B. Tell the father to wait in the waiting room.
- C. Notify the child’s mother to come to the ED.
- D. Call the police department to come and arrest him.
Correct Answer: A
Rationale: A calm, low voice de-escalates the situation, promoting safety. Waiting room relocation, notifying the mother, or police involvement may escalate or delay resolution.