Nokea
The nurse is caring for an 11-year-old child who has been physically abused. Which therapeutic action should the nurse include in the plan of care?
- A. Encouraging the child to confront the abuser
- B. Providing a care environment that fosters trust
- C. Teaching the child to make wise choices when faced with possible abuse
- D. Reinforcing for the child that not all adults are capable of abusing children
Correct Answer: B
Rationale: Providing a safe and trusting environment is critical for a child who has experienced physical abuse, as it helps the child feel secure and supported, facilitating emotional healing. Encouraging the child to confront the abuser is inappropriate and could be traumatic, especially for a young child. Teaching the child to make wise choices in potentially abusive situations places an unrealistic burden on the child, who may not have the capacity to protect themselves. Reinforcing that not all adults are abusive is less immediate and does not directly address the child's need for a safe and trusting care environment.
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The nurse is caring for an elderly female client who presents as being alert and oriented. In the late afternoon, the client becomes extremely agitated and confused. Which of the following responses by the nurse is most appropriate?
- A. call a family member to come and stay with the client
- B. call the health care provider and ask for an order for Xanax
- C. reorient the client and offer distraction and reassurance in a soft voice
- D. tell the client that if she does not cooperate, she will be placed in restraints
Correct Answer: C
Rationale: This behavior suggests sundowning, common in elderly clients. Reorientation and reassurance are appropriate non-pharmacological interventions.
Which comment made by the parents of a male infant who will have a surgical repair of a hernia indicates a need for further teaching by the nurse?
- A. I understand that surgery will repair the hernia.'
- B. I don't know if he will be able to father a child when he grows up.'
- C. The day nurse told me to give him sponge baths for a few days after surgery.'
- D. I'll need to buy extra diapers because we need to change them frequently now.'
Correct Answer: B
Rationale: The anatomical location of a hernia frequently causes more psychological concern to the parents than does the actual condition or treatment. The remaining options all indicate accurate understanding associated with the surgery. The correct option is an incorrect comment requiring follow-up.
The nurse is assessing a client who is a polysubstance abuser, with fentanyl being one of the drugs most frequently used. Which physiological symptoms are suggestive of fentanyl intoxication? Select all that apply.
- A. diarrhea
- B. nausea
- C. urge to urinate
- D. anxiety
Correct Answer: B
Rationale: Nausea is a common symptom of fentanyl intoxication. Diarrhea, urge to urinate, and anxiety are not typical physiological signs.
A new mother is trying to decide whether to have her baby boy circumcised. The nurse should make which statement to assist the mother with making the decision?
- A. Discuss the procedure with the male members of your family.'
- B. Circumcision is a difficult decision, but your primary health care provider is the best, and it's better to get it done now than later.'
- C. You know they say it prevents cancer and sexually transmitted infections, so I would definitely have my son circumcised.'
- D. Circumcision is a difficult decision. Here, read this pamphlet that discusses the pros and cons, and we will talk about any questions that you have after you read it.'
Correct Answer: D
Rationale: Informed decision making is the strategic point when answering this question. The nurse should provide educational materials and answer questions pertaining to the education of the mother. Providing written information to the mother will give her the information she needs to make an educated and informed decision. The nurse's personal thoughts and feelings should not be part of the educational process. The remaining options are not well focused on answering the mother's concerns.
The nurse is caring for a client diagnosed with left-sided Bell's palsy. Which statement by the client shows a need for further teaching by the nurse?
- A. My left eye is tearing a lot.'
- B. I have trouble closing my left eyelid.'
- C. I don't know how I'll live with this stroke.'
- D. I can't feel anything on the left side of my face.'
Correct Answer: C
Rationale: Bell's palsy is an inflammatory condition that involves the facial nerve (cranial nerve VII). Although it results in facial paralysis, it is not the same as a stroke. Many clients fear that they have had a stroke when the symptoms of Bell's palsy appear, and they commonly believe that the paralysis is permanent. Symptoms resolve, although it may take several weeks. The remaining options are expected assessment findings of the client with Bell's palsy.