Nokea
The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?
- A. How did you get those bruises?'
- B. Did someone grab you by your arms?'
- C. Do you fall often?'
- D. What did you bump against?'
Correct Answer: B
Rationale: Using a direct approach is best when asking about suspected abuse. Clients are reluctant to report abuse because of shame and fear of reprisal.
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A nurse is instructing a person who had a left CVA and right lower extremity hemiparesis to use a quad cane. Which of the following is the most appropriate gait sequence?
- A. Place the cane in the patient's left upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
- B. Place the cane in the patient's left upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
- C. Place the cane in the patient's right upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
- D. Place the cane in the patient's right upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
Correct Answer: A
Rationale: The cane should be placed in the patient's strong upper extremity (left), and the sequence should coordinate the weak side (right leg) with the cane for support, followed by the strong side (left leg).
A nurse gave medications to the wrong client. She stated the client responded to the name called. What is the nurse's appropriate documentation?
- A. Note in medication records the drug given
- B. The client was not hurt, no need for documentation
- C. Note the client's orientation
- D. Completely fill out an incident report
Correct Answer: D
Rationale: The incident report should always be filled out involving medication errors.
Support systems during the grieving process include all of the following except:
- A. a despondent friend.
- B. a nurse.
- C. a social worker.
- D. a family member.
Correct Answer: A
Rationale: A despondent friend, even though this could be a support to the grieving person, is in a state of despondency. Therefore, he or she might not do well with a grieving friend.
With a breech presentation, the nurse must be particularly alert for which of the following?
- A. quickening
- B. ophthalmia neonatorum
- C. pica
- D. prolapsed umbilical cord
Correct Answer: D
Rationale: Prolapsed umbilical cord is the descent of the umbilical cord into the vagina before the fetal presenting part and compression of the cord between the presenting part and the maternal pelvis, compromising or completely cutting off fetoplacental perfusion. This is an emergency situation; immediate delivery should be attempted to save the fetus.
The kind of man who beats a woman is:
- A. from a minority culture in a low-income group.
- B. from a majority culture in a middle-income group.
- C. one who was never allowed to compete as a child.
- D. from any walk of life, race, income group, or profession.
Correct Answer: D
Rationale: Batterers cannot be predicted by demographic features related to age, ethnicity, race, religious denomination, education, socioeconomic status, or class. Ninety-five percent of domestic abuse cases involve male perpetrators and female victims.