Nokea
The nurse is caring for a client with a history of burns. Which of the following psychosocial interventions should be included in the plan of care?
- A. Encourage expression of feelings.
- B. Restrict family visits.
- C. Limit social interactions.
- D. Provide sedatives routinely.
Correct Answer: A
Rationale: Encouraging expression of feelings supports emotional coping in burn recovery.
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The nurse is assessing a 55-year-old client with chronic obstructive pulmonary disease. The client weighs 200 lb and is 6 feet tall. Using the diagram shown here, the nurse should record in the health history that the client's chest is:
- A. Barrel-shaped
- B. Muscular
- C. Normal for the client's age, height, and weight
- D. Showing the effects of long-term use of bronchodilators
Correct Answer: A
Rationale: A barrel-shaped chest is characteristic of chronic obstructive pulmonary disease due to hyperinflation of the lungs, which is likely in this client. The client's weight and height suggest a normal body habitus, not a muscular chest, and bronchodilator use does not directly cause this chest shape.
A postoperative client has been placed on a clear liquid diet. Which items is the client allowed to consume? Select all that apply.
- A. Tea
- B. Broth
- C. Gelatin
- D. Pudding
- E. Vegetable juice
- F. Pureed vegetables
Correct Answer: A,B,C
Rationale: A clear liquid diet consists of foods that are relatively transparent to light, and are clear and liquid at room and body temperature. These foods include such items as water, either regular or decaffeinated coffee or tea, bouillon, clear broth, gelatin, carbonated beverages, hard candy, lemonade, and popsicles. The incorrect food items are items that are allowed on a full liquid diet.
An I.V. infusion is to be administered through a scalp vein on an infant's head. What should the nurse tell the parents to prepare them for the procedure?
- A. It may be necessary to remove a small amount of hair from the infant's scalp.
- B. A sedative will be given to help keep the infant quiet.
- C. Administering the infant will be delayed until the infusion has been completed.
- D. Holding the infant will be contraindicated while the infusion is being administered.
Correct Answer: A
Rationale: Removing a small amount of hair may be necessary to secure the I.V. site on the scalp.
Which couple is at greatest risk for domestic violence?
- A. A couple which consists of a husband and wife both of whom are affected with Alzheimer's disease
- B. A poverty stricken couple without any healthcare resources in the community
- C. A pregnant woman and a husband who was physically abused as a young child
- D. A wealthy couple with feelings that they are immune from punishment and above the law
Correct Answer: C
Rationale: A history of childhood physical abuse is a significant risk factor for perpetrating domestic violence, as it may lead to learned behaviors or unresolved trauma. Pregnancy can also increase stress and vulnerability, further elevating the risk.
The nurse is planning discharge care with the parents of a 16-year-old boy who recently attempted suicide. The nurse should advise the parents to tell the nurse if their son:
- A. Expresses a desire to date.
- B. Decides to try out for an extracurricular activity.
- C. Gives away valued personal items.
- D. Desires to spend more time with his friends.
Correct Answer: C
Rationale: Giving away valued items is a warning sign of suicidal intent, requiring immediate reporting. The other behaviors are normal adolescent activities.