Nokea
The nurse working in a homeless shelter identifies an adolescent female sexually aggressive toward some of the males in the shelter. Which is the most common cause for this behavior?
- A. The client is acting in a learned behavior pattern to get attention.
- B. The client had to leave home because of promiscuous behavior.
- C. The client has a psychiatric disorder called nymphomania.
- D. The client is a prostitute and is trying to get customers.
Correct Answer: A
Rationale: Sexual aggression in adolescents often reflects learned behavior from past abuse or trauma, seeking attention or control. Promiscuity, nymphomania, or prostitution are less likely or outdated terms.
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A vat of chemicals spilled onto the client. Which action should the occupational health nurse implement first?
- A. Have the client stand under a shower while removing all clothes.
- B. Check the material safety data sheets for the antidote.
- C. Administer oxygen by nasal cannula.
- D. Collect a sample of the chemicals in the vat for analysis.
Correct Answer: A
Rationale: Removing clothes and showering decontaminates the skin, preventing further chemical absorption. MSDS, oxygen, and sampling are secondary.
The client with a temperature of 94°F is being treated in the ED. Which intervention should the nurse implement to directly elevate the client’s temperature?
- A. Remove the client’s clothing.
- B. Place a warm air blanket over the client.
- C. Have the client change into a hospital gown.
- D. Raise the temperature in the room.
Correct Answer: B
Rationale: A warm air blanket (e.g., Bair Hugger) directly raises core temperature in hypothermia. Removing clothing, changing gowns, or room temperature are less effective.
The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first?
- A. Start an IV with an 18-gauge catheter.
- B. Administer dopamine intravenous infusion.
- C. Obtain arterial blood gases (ABGs).
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: Hypovolemic shock (suggested by symptoms) requires immediate IV access for fluid resuscitation. Dopamine requires IV access, ABGs are diagnostic, and urinary catheter monitors output but is secondary.
The nurse is providing first aid to a victim of a poisonous snake bite. Which intervention should be the nurse’s first action?
- A. Apply a tourniquet to the affected limb.
- B. Cut an 'X' across the bite and suck out the venom.
- C. Administer a corticosteroid medication.
- D. Have the client lie still and remove constrictive items.
Correct Answer: D
Rationale: Immobilizing the limb and removing constrictive items (e.g., jewelry) prevents venom spread and swelling, the first action. Tourniquets, cutting, and steroids are outdated or secondary.
The client has expired secondary to smallpox. Which information about funeral arrangements is most important for the nurse to provide to the client’s family?
- A. The client should be cremated.
- B. Suggest an open casket funeral.
- C. Bury the client within 24 hours.
- D. Notify the public health department.
Correct Answer: D
Rationale: Notifying the public health department is critical for smallpox, a highly contagious disease, to ensure containment. Cremation, open caskets, and rapid burial are secondary.