Nokea
The nurse is planning a staff education program about intimate partner violence. Which of the following information should the nurse include? Select all that apply.
- A. Intimate partner violence is most common in high-income families.
- B. Intimate partner violence is rare in same-sex partnerships.
- C. The abusive partner often demonstrates jealousy and possessiveness.
- D. Victims may not leave due to financial concerns or fear of harm by the abuser.
- E. Violence against a female often intensifies during pregnancy.
Correct Answer: C,D,E
Rationale: Jealousy/possessiveness, barriers to leaving (financial/fear), and increased violence during pregnancy are accurate. Violence is not limited to high-income families and occurs in same-sex partnerships.
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The nurse is caring for clients who are having the following procedures. Which client should be asked about allergies to shellfish?
- A. The client who is having an arthroscopy
- B. The client who is having an arthrocentesis
- C. The client who is having a myelogram
- D. The client who is having an electromyogram (EMG)
Correct Answer: C
Rationale: Myelograms often use iodine-based contrast; shellfish allergies may indicate iodine sensitivity, requiring verification. Arthroscopy, arthrocentesis, and EMG do not typically involve contrast.
The nurse is caring for a postoperative client with a Hemovac drain. Which task request is inappropriate for the nurse to make to the experienced unlicensed assistive personnel?
- A. Please change the sterile dressing on the Hemovac drain insertion site when you bathe the client
- B. Please measure the Hemovac drainage at 2:00 PM and let me know how much there was.
- C. Please record the amount of Hemovac drainage on the intake and output record at the end of the shift
- D. Please remember to compress the Hemovac device immediately after emptying it to restore negative pressure, as you were taught.
Correct Answer: A
Rationale: Changing a sterile dressing is a nursing task requiring sterile technique, inappropriate for unlicensed personnel. Measuring, recording, and compressing the Hemovac are within their scope.
An adult who had a mastectomy yesterday says to the nurse, 'I guess I'm not a real woman anymore. How could my husband possibly love me now?' What is the best response for the nurse to make?
- A. You don't feel like a woman now?'
- B. Has your husband said anything to you?'
- C. Of course your husband will love you.'
- D. True love is not dependent on breasts.'
Correct Answer: A
Rationale: Reflecting the client's feelings validates her emotional distress, fostering therapeutic communication post-mastectomy. Other responses dismiss or redirect her concerns.
A client is scheduled for a percutaneous kidney biopsy at 1000. The practical nurse reviews the client's vital signs and most current serum laboratory results at 0600. Which of the following client findings is most important to report to the registered nurse?
- A. hemoglobin of 9.8 g/dL (98 g/L)
- B. blood pressure of 180/100 mm Hg
- C. creatinine of 2.0 mg/dL (177 µmol/L)
- D. platelet count of 120,000/mm³ (120 × 10â¹/L)
Correct Answer: B
Rationale: Severe hypertension (180/100 mm Hg) increases bleeding risk during a kidney biopsy, requiring immediate reporting. Other findings are concerning but less urgent.
Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner's injuries by
- A. Seeking medical help for the victim's injuries
- B. Minimizing the episode and underestimating the victim's injuries
- C. Contacting a close friend and asking for help
- D. Being very remorseful and assisting the victim with medical care
Correct Answer: B
Rationale: Minimizing the episode and underestimating the victim's injuries. Batterers often use denial to downplay the severity of their actions.