Nokea
The nurse is teaching a community group about violence in the family. Which statement by a group member about abusers would indicate a need for further teaching?
- A. They use fear and intimidation.
- B. They usually have poor self-esteem.
- C. They are often jealous or self-centered.
- D. They are more often from low-income families.
Correct Answer: D
Rationale: Personal characteristics of abusers include low self-esteem, immaturity, dependence, insecurity, and jealousy. The statement that abusers are more common among low-income families is inaccurate. The remaining options do describe characteristics of abusers who often use fear and intimidation to the point where their victims will do anything just to avoid further abuse.
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A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal distention. Which of the following interventions would be most appropriate? Select all that apply.
- A. Change the feeding apparatus every 24 hours.
- B. Use a higher volume of formula because the normal loss of the blood pressure.
- C. Slow the administration rate.
- D. Use a diluted formula, gradually increasing the volume and concentration.
- E. Anticipate changing to a lactose-free formula.
Correct Answer: A, C, D, E
Rationale: Changing the apparatus, slowing the rate, using diluted formula, and switching to lactose-free formula help manage diarrhea and distention.
Assessment of a primigravid client in active labor reveals a cervix dilated to 5 cm and completely effaced, with the fetus at -1 station. The client has indicated that she wants a 'natural childbirth' with no analgesia or anesthesia. The client's husband has been present since their arrival at the birthing unit. The physician enters the room and tells the client that it is time for an epidural anesthetic. Which of the following would be the nurse's best action at this time?
- A. Ask the client if she desires an epidural anesthetic.
- B. Tell the physician that the client desires a natural childbirth with no analgesia or anesthesia.
- C. Tell the client that her labor will be more comfortable with an anesthetic.
- D. Ask the client to discuss this with her husband and then make a decision.
Correct Answer: B
Rationale: Advocating for the client's stated preference for natural childbirth ensures autonomy and respects her birth plan.
A client with a history of breast cancer is prescribed anastrozole (Arimidex). The nurse should monitor the client for which of the following adverse effects?
- A. Bone loss.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Anastrozole, an aromatase inhibitor, can cause bone loss, increasing osteoporosis risk.
The nurse should turn the client on bed rest every 2 hours to prevent the development of pressure ulcers. In addition, the nurse should:
- A. Have the client walk at least twice a day
- B. Insert an indwelling urinary catheter
- C. Monitor serum albumin
- D. Monitor the white blood cell count
Correct Answer: C
Rationale: Monitoring serum albumin assesses nutritional status, which is critical for skin integrity and preventing pressure ulcers. Walking is contraindicated for bed rest, catheters increase infection risk, and white blood cell count is less relevant.
A 10-year-old child with asthma is prescribed an albuterol inhaler. The nurse should teach the child to:
- A. Use the inhaler daily regardless of symptoms
- B. Rinse the mouth after each use
- C. Inhale rapidly during administration
- D. Use the inhaler before a spacer
Correct Answer: B
Rationale: Rinsing the mouth after using an albuterol inhaler prevents oral irritation and reduces the risk of thrush, especially if used with a corticosteroid.