What is a common characteristic of a batterer?
- A. Grew up in a loving, secure home
- B. Was an only child
- C. Was physically or psychologically abused
- D. Admits they have a problem with anger
Correct Answer: C
Rationale: The correct answer is that a batterer is typically someone who was physically or psychologically abused. Research shows that many individuals who engage in abusive behavior report a history of being abused themselves. Choices A, B, and D are incorrect. While it is possible for a batterer to have grown up in a loving, secure home, been an only child, or acknowledge their anger issues, the most common factor associated with becoming a batterer is a history of being abused.
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The nurse is working with families who have been displaced by a fire in an apartment complex. What is the priority intervention during the initial assessment?
- A. Provide a liaison to meet housing needs.
- B. Attentively listen when clients describe their feelings.
- C. Offer nurturing support for clients who are confused by the events.
- D. Provide structure for clients exhibiting moderate to severe anxiety.
Correct Answer: A
Rationale: The correct answer is to provide a liaison to meet housing needs. In the initial assessment after a disaster like a fire, ensuring basic needs such as housing, clothing, and food are met is the priority. Once the physical needs are addressed, the nurse can then focus on assisting clients in managing the psychological effects of loss. Choices B, C, and D are not the priority during the initial assessment as addressing housing needs should come first to provide a sense of stability and security for the affected families.
The nurse is making initial rounds on a client with a C5 fracture and crutch field tongs. Which equipment should be kept at the bedside?
- A. A pair of forceps
- B. A torque wrench
- C. A pair of wire cutters
- D. A screwdriver
Correct Answer: B
Rationale: A torque wrench is essential equipment to keep at the bedside for a client with a C5 fracture and crutch field tongs. This tool is used to tighten and loosen the screws of the crutch field tongs, allowing the nurse to adjust the pressure on the screws for proper support and alignment. A pair of forceps (choice A), wire cutters (choice C), and a screwdriver (choice D) are not required for managing crutch field tongs and, therefore, are incorrect choices in this scenario.
The client with diverticulosis is being assisted by the nurse in selecting appropriate foods. Which food should be avoided?
- A. Bran
- B. Fresh peaches
- C. Cucumber salad
- D. Yeast rolls
Correct Answer: C
Rationale: The food that should be avoided for a client with diverticulosis is Cucumber salad. Foods with seeds should be avoided as they can aggravate diverticulosis by causing irritation and inflammation in the diverticula. Choices A, B, and D are allowed and even beneficial. Bran cereal and fruit like fresh peaches can help prevent constipation, which is beneficial for individuals with diverticulosis. Yeast rolls are also acceptable unless the client has specific dietary restrictions related to yeast or gluten.
A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate?
- A. Blood pressure monitoring every 15 minutes
- B. Insertion of a Levine tube
- C. Continuous cardiac monitoring
- D. Administration of pain medication every 4 hours
Correct Answer: B
Rationale: In a client with pancreatitis who frequently experiences nausea and vomiting, insertion of a Levine tube is often anticipated to decompress the stomach and rest the bowel, helping to alleviate symptoms. This intervention is crucial in managing the gastrointestinal symptoms associated with pancreatitis. Blood pressure monitoring every 15 minutes may be necessary in some cases, but it is not a routine order for pancreatitis, making option A less likely. Continuous cardiac monitoring could be required based on the individual's condition, but it is not typically the first priority in pancreatitis management, so option C is not the most anticipated order. While pain medication administration is essential for managing discomfort, the priority in this scenario, especially considering the symptoms of nausea and vomiting, would be decompression with a Levine tube to address gastrointestinal issues, making option D less likely.
During the history assessment of an 80-year-old client, which statement made by the client might indicate a possible fluid and electrolyte imbalance?
- A. "My skin is always so dry."?
- B. "I often use a laxative for constipation."?
- C. "I have always liked to drink a lot of iced tea."?
- D. "I sometimes have a problem with dribbling urine."?
Correct Answer: B
Rationale: The correct answer is "I often use a laxative for constipation." Frequent use of laxatives can lead to diarrhea and electrolyte loss, indicating a possible fluid and electrolyte imbalance. Statements A, C, and D are not directly related to fluid and electrolyte imbalance. Statement A about dry skin may suggest dehydration, but it is less specific to electrolyte imbalance than the frequent use of laxatives. Statement C about drinking a lot of iced tea could potentially relate to fluid intake, but it doesn't directly indicate an imbalance. Statement D about dribbling urine is more indicative of a potential urinary issue rather than a fluid and electrolyte imbalance.