Nokea
The nurse is caring for a woman who is admitted following a beating by her husband. The woman says, 'It wasn't really his fault. Dinner was late.' The husband arrives to visit his wife with a large bouquet of flowers and a box of chocolates. The woman later says to the nurse, 'He feels so bad about what he did and says it will never happen again.' What concept should guide the nurse when replying to the client?
- A. Men who abuse their wives and then repent usually do not do it again.
- B. The woman is quite perceptive and should be safe when she is discharged.
- C. Abuse is often followed by repentance and then again by abuse.
- D. Spousal abuse is usually a result of misbehavior on the part of the abused.
Correct Answer: C
Rationale: The cycle of abuse often includes remorse followed by repeated abuse, guiding the nurse to educate about patterns, not assume safety or blame the victim.
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Which of the following should be included in the discharge teaching of a client with a unilateral adrenalectomy?
- A. The client's need to pay close attention to skin care
- B. The client's need to restrict dietary intake of sodium and protein
- C. The client's need to recognize signs of hypoglycemia
- D. The client's need for daily steroid medication
Correct Answer: D
Rationale: Unilateral adrenalectomy may impair cortisol production, requiring lifelong steroid replacement. Skin care, dietary restrictions, and hypoglycemia are not primary concerns.
The client asks the nurse how the health care provider could tell she was pregnant 'just by looking inside.' What is the best explanation by the nurse?
- A. Bluish coloration of the cervix and vaginal walls
- B. Pronounced softening of the cervix
- C. Clot of very thick mucous that obstructs the cervical canal
- D. Slight rotation of the uterus to the right
Correct Answer: A
Rationale: Chadwick's sign is a bluish-purple coloration of the cervix and vaginal walls, occurring at 4 weeks of pregnancy, that is caused by vasocongestion.
A man is presently employed as a night watchman. When he comes to the clinic for a visit, he tells the nurse he is having difficulty sleeping and is fatigued much of the time.
Which of the following responses by the nurse is BEST?
- A. Tell me about your usual sleeping habits.'
- B. You probably sleep when you can during your night tour.'
- C. This is normal for your age group.'
- D. Working the night shift is known to disrupt sleep patterns.'
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) correct-assessment, open-ended, encourages discussion (2) judgment based on inadequate information, nontherapeutic (3) generalization with no factual basis, closed communication (4) closed communication, generalization
A client with a marked depression of T cells.
To promote safety in the environment of a client with a marked depression of T cells, the nurse should
- A. keep a linen hamper immediately outside the room.
- B. restrict eating utensils to spoons made of plastic.
- C. provide masks for anyone entering the room.
- D. remove any standing water left in containers or equipment.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) protocol for handling soiled articles is accomplished within universal guidelines with double biohazard bags (2) universal precautions and client protection may call for plastic utensils, but not just spoons (3) not protocol unless the client has an active pulmonary infection (4) correct-water should not be allowed to stand in containers, such as respiratory or suction equipment, because this could act as a culture medium
A 26-year-old woman has missed her menstrual period. The client's last menstrual period began May 8 and ended May 12.
The nurse determines that her EDC (estimated date of confinement) is
- A. February 1.
- B. February 15.
- C. February 19.
- D. March 14.
Correct Answer: B
Rationale: Strategy: Remember Naegele's rule. (1) should add seven days (2) correct-when using the Naegele rule, add seven days to first day of last menstrual period and subtract three months (3) incorrectly started with the last day of the menstrual cycle (4) incorrect