Nokea
What is the primary purpose of administering Rho(D) immune globulin (RhoGAM) to an Rh-negative mother after childbirth?
- A. To prevent Rh sensitization in future pregnancies
- B. To treat anemia in the newborn
- C. To increase the mother's white blood cell count
- D. To prevent infection in the newborn
Correct Answer: A
Rationale: The correct answer is A: To prevent Rh sensitization in future pregnancies. RhoGAM is given to an Rh-negative mother to prevent the development of antibodies against Rh-positive blood cells. This prevents Rh sensitization, which could lead to hemolytic disease in future Rh-positive pregnancies. Choices B, C, and D are incorrect because RhoGAM is not used to treat anemia in the newborn, increase the mother's white blood cell count, or prevent infection in the newborn.
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For an older postoperative client with the nursing diagnosis 'impaired mobility related to fear of falling,' which desired outcome best directs the nurse's actions for the client?
- A. The client will ambulate with assistance every 4 hours
- B. The physical therapist will instruct the client in the use of a walker
- C. The client will use self-affirmation statements to decrease fear
- D. The nurse will place a gait belt on the client prior to ambulation
Correct Answer: C
Rationale: Encouraging the client to use self-affirmation statements is the most appropriate desired outcome in this scenario. By utilizing self-affirmation statements, the client can address their fears directly and build confidence, which can ultimately lead to a reduction in fear of falling. While ambulating with assistance (choice A) is important, the focus here is on addressing the fear itself. Instructing the client in the use of a walker (choice B) and placing a gait belt on the client (choice D) are interventions that may be helpful but do not directly address the client's fear of falling.
Which of the following is NOT a second-line agent used for the treatment of Tuberculosis?
- A. Amikacin
- B. Moxifloxacin
- C. Rifabutin
- D. Cycloserine
Correct Answer: C
Rationale: The correct answer is C, Rifabutin. Rifabutin is actually a first-line drug used in the treatment of tuberculosis. Choices A, B, and D (Amikacin, Moxifloxacin, and Cycloserine) are considered second-line agents for tuberculosis treatment. These drugs are used when the first-line medications are either ineffective or cannot be tolerated by the patient.
In a group therapy setting, one member is very demanding, repeatedly interrupting others and taking most of the group time. The nurse's best response would be:
- A. Will you briefly summarize your point because others need time as well?
- B. Your behavior is obnoxious and drains the group.
- C. I am so frustrated with your behavior.
- D. To ignore the behavior and allow him to vent
Correct Answer: A
Rationale: In a group therapy setting, where each member should have the opportunity to participate, it is essential for the nurse to manage disruptive behavior assertively yet respectfully. Choice A is the best response as it addresses the issue of one member dominating the group time by asking them to summarize their point briefly, allowing others to contribute. Choice B is confrontational and may alienate the individual, hindering the therapeutic process. Choice C expresses personal frustration, which is not constructive in managing the situation. Choice D of ignoring the behavior is not effective as it allows the disruptive behavior to continue, impacting the group dynamics negatively.
A Native American client is admitted with a diagnosis of psychosis not otherwise specified. The client's family seems to regard the client's hallucinations as normal. What assessment can be made?
- A. The client's family regards the hallucinations from a cultural context
- B. The client will benefit from a talking circle
- C. The client will need a medicine man
- D. The client will need a single room
Correct Answer: A
Rationale: Choice A is correct because the family may interpret the client's hallucinations through their cultural lens, potentially viewing them as normal or spiritually significant. Understanding and acknowledging the cultural context is essential for providing culturally sensitive care. Choices B, C, and D are incorrect because while talking circles and seeking guidance from a medicine man may be culturally relevant interventions in some contexts, the priority in this situation is to recognize and respect the family's perspective on the client's hallucinations.
When assisting an older male client recovering from a stroke to ambulate with a cane, where should the nurse place the cane in relation to the client's body?
- A. In front of the body to lean on while stepping forward
- B. On the opposite side of the affected extremity
- C. Approximately one foot away from the body to stabilize balance
- D. On the same side as the affected extremity
Correct Answer: B
Rationale: The correct answer is B: 'On the opposite side of the affected extremity.' Placing the cane on the opposite side of the affected extremity provides maximum support and stability during ambulation for a client recovering from a stroke. This positioning helps to offload weight from the affected side and improves balance. Choice A is incorrect because placing the cane in front of the body can lead to incorrect weight distribution and instability. Choice C is incorrect as placing the cane one foot away from the body may not provide adequate support and can compromise balance. Choice D is incorrect as placing the cane on the same side as the affected extremity does not offer the necessary balance and support needed for safe ambulation.