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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Neural tube defects in the fetus have been primarily associated with which deficiency in the mother?
- A. iron
- B. folic acid
- C. vitamin B12
- D. vitamin E
Correct Answer: B
Rationale: Folic acid is essential for the development of the neural tube and might prevent the defect or failure of the tube to close (congenital anomalies).
The nurse is assessing an elder who the nurse suspects is being physically abused. The most important question for nurse to ask is:
- A. How much money do you keep around the house?
- B. Who provides your physical care?
- C. How close does your nearest relative live?
- D. What form of transportation do you use?
Correct Answer: B
Rationale: The most common abuser is a caregiver living with the client. Research reveals that the spouse is currently the most common abuser, followed by an adult child.
Elderly persons with pernicious anemia should be instructed:
- A. to increase their dietary intake of foods high in B12.
- B. that they do not need to return for follow-up for at least a month after initiation of treatment.
- C. that oral B12 is safer and less expensive than parenteral replacement.
- D. that diarrhea can be a transient side effect of B12 injections.
Correct Answer: D
Rationale: Pernicious anemia is a megaloblastic, macrocytic, normochronic anemia caused by a deficiency of the intrinsic factor produced by the stomach. This results in malabsorption of vitamin B12, which is necessary for DNA synthesis and maturation of RBC. Education should include side effects of Vitamin B12, which can include pain and burning at the injection site, peripheral vascular thrombosis, and transient diarrhea.
A client goes to the mental health center for difficulty concentrating, insomnia, and nightmares. The client reports being raped as a child. The nurse should assess the client for further signs of:
- A. General anxiety disorder
- B. Schizophrenia
- C. Post-traumatic stress disorder
- D. Bipolar disorder
Correct Answer: C
Rationale: Childhood sexual abuse is strongly associated with post-traumatic stress disorder (PTSD), characterized by nightmares, insomnia, and concentration difficulties.
A nurse is performing a screening on a patient that has been casted recently on the left lower extremity. Which of the following statements should the nurse be most concerned about?
- A. The patient reports, 'I didn't keep my extremity elevated like the doctor asked me to.'
- B. The patient reports, 'I have been having pain in my left calf.'
- C. The patient reports, 'My left leg has really been itching.'
- D. The patient reports, 'The arthritis in my wrists is flaring up, when I put weight on my crutches.'
Correct Answer: B
Rationale: Pain may be indicating neurovascular complication.