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The nurse in the emergency department has admitted five (5) clients in the last two (2) hours with complaints of fever and gastrointestinal distress. Which question is most appropriate for the nurse to ask each client to determine if there is a bioterrorism threat?
- A. Do you work or live near any large power lines?
- B. Where were you immediately before you got sick?
- C. Can you write down everything you ate today?
- D. What other health problems do you have?
Correct Answer: B
Rationale: Asking about recent locations identifies potential common exposure points, critical for bioterrorism. Power lines, food intake, and comorbidities are less relevant.
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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.
The 84-year-old female client is admitted with multiple burn marks on the torso and under the breasts along with contusions in various stages of healing. When questioned by the nurse, the woman denies any problems have occurred. The woman lives with her son and does the housework. Which is the most probable reason the woman denies being abused?
- A. There has not been any abuse to report.
- B. The client is ashamed to admit being abused.
- C. The client has Alzheimer’s disease and can’t remember.
- D. The client has engaged in consensual sex.
Correct Answer: B
Rationale: Shame often leads elderly abuse victims to deny abuse, especially when dependent on the abuser (e.g., son). Lack of abuse is unlikely given findings, Alzheimer’s is speculative, and sex is unrelated.
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 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 emergency department nurse writes the problem of 'ineffective coping' for a client who has been raped. Which intervention should the nurse implement?
- A. Encourage the client to take the 'morning-after' pill.
- B. Allow the client to admit guilt for causing the rape.
- C. Provide a list of rape crisis counselors.
- D. Discuss reporting the case to the police.
Correct Answer: C
Rationale: Rape crisis counselors provide specialized support for coping post-rape. Morning-after pill addresses pregnancy, guilt admission is harmful, and police reporting is client-driven.