Nokea
A home health nurse is speaking to a group of acute care nurses about domestic violence. Which of the following statements by one of the acute care nurses indicates a need for clarification?
- A. "I have heard that abusers try to keep their partner isolated from others."
- B. "I know that abusers lack social supports and social skills."
- C. "I know that men who are abusers gain power through intimidation."
- D. "I have heard that abusers think of themselves as important and have high self-esteem."
Correct Answer: D
Rationale: Answer D indicates a need for clarification because it presents a misconception about abusers. Abusers typically have low self-esteem and use power and control to compensate. This statement falsely suggests that abusers have high self-esteem and view themselves as important. This misunderstanding could lead to overlooking warning signs and risks associated with domestic violence. It's crucial for healthcare professionals to recognize the true dynamics of abusive relationships to provide appropriate support and interventions. Other choices (A, B, C) align with common knowledge about domestic violence, highlighting the tactics and behaviors typically associated with abusers.
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A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?
- A. "My parents treat me like a baby sometimes."
- B. "I haven't gotten my period yet, and all my friends have theirs."
- C. "None of the kids at this school like me, and I don't like them either."
- D. "There's a big pimple on my face, and I worry that everyone will notice it."
Correct Answer: C
Rationale: The correct answer is C. The nurse's priority should be to address the adolescent's statement about not liking any kids at school and feeling disliked by others. This suggests potential social isolation, which can impact mental health and well-being. Addressing social relationships is crucial at this age for emotional development. Choices A, B, and D are important but not urgent concerns. Choice A relates to family dynamics, B to physical development, and D to self-image; while these are valid issues, they do not have immediate implications for the adolescent's well-being like the social isolation expressed in choice C.
A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make?
- A. "You have a great deal to live for."
- B. "It’s not unusual for depressed people to feel that way."
- C. "Why do you feel you are worthless?"
- D. "You’ve been feeling that your life has no meaning."
Correct Answer: D
Rationale: Reflecting the client’s emotions helps encourage further discussion.
A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? (Select all that apply.)
- A. Contact the laboratory to obtain a blood sample.
- B. Prepare the client for a CT scan.
- C. Check the client’s pupil reactivity.
- D. Obtain a urine specimen.
- E. Perform a developmental screening test.
Correct Answer: A, B, C, D
Rationale: The correct interventions for a client experiencing alcohol intoxication are A, B, C, and D. A blood sample is crucial to assess alcohol levels. A CT scan may be needed to rule out head trauma or other underlying issues. Checking pupil reactivity can indicate neurological status. Obtaining a urine specimen helps assess kidney function and possible drug use. Choice E, performing a developmental screening test, is not relevant to the immediate care needs of an individual with alcohol intoxication.
A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?
- A. Prepare for gastric lavage due to an extremely elevated lithium level.
- B. Administer the morning dose of lithium.
- C. Check the client's medication record to assess whether the client has been refusing her lithium.
- D. Hold the medication and assess for early manifestations of toxicity.
Correct Answer: B
Rationale: A lithium level of 1.0 mEq/L is within the therapeutic range (0.6-1.2 mEq/L).
A charge nurse is admitting a client who has bipolar disorder and who is in the manic phase. Which of the following room assignments should the nurse give the client?
- A. A semi-private room across from the day room.
- B. A private room in a quiet location on the unit.
- C. A private room across from the exercise room.
- D. A semi-private room across from the snack area.
Correct Answer: B
Rationale: The correct answer is B: A private room in a quiet location on the unit. This choice minimizes stimuli and provides a calm environment, essential for managing manic symptoms. A quiet location reduces potential triggers for agitation or impulsivity. Semi-private rooms (A, D) may lead to conflicts with roommates. Rooms near common areas (C, D) can be noisy and disruptive. Overall, choice B promotes client safety and well-being during the manic phase.