Nokea
When a client has a tearing of tissue with irregular wound edges, the nurse should document this as:
- A. Contusion
- B. Abrasion
- C. Laceration
- D. Colonization
Correct Answer: C
Rationale: A laceration is characterized by tearing of tissue with irregular wound edges. Contusions are bruises, abrasions are superficial, and colonization refers to bacterial presence, not wound type.
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Your client is receiving brachytherapy. What nursing intervention should you implement for this client?
- A. Exclude pregnant visitors from the client's room.
- B. Place the client in a negative pressure room.
- C. Have all visitors wear protective masks and boots.
- D. All of the above
Correct Answer: A
Rationale: Brachytherapy involves internal radiation, posing a risk to pregnant individuals due to radiation exposure. Excluding pregnant visitors minimizes this risk.
A client with severe major depression states, 'My heart has stopped and my blood is black ash.' The nurse interprets this statement to be evidence of which of the following?
- A. Hallucination.
- B. Illusion.
- C. Delusion.
- D. Paranoia.
Correct Answer: C
Rationale: The client's statement reflects a false, fixed belief that is not based in reality, which is characteristic of a delusion. Hallucinations involve sensory perceptions, illusions are misinterpretations of stimuli, and paranoia involves suspicion, none of which fit this scenario.
The nurse is assessing a teenage girl. According to the fi gure below, the nurse should note that the girl has:
- A. Kyphosis.
- B. Arthritis.
- C. Developmental dysplasia of the hip.
- D. Scoliosis.
Correct Answer: D
Rationale: The teenage girl has scoliosis, the lateral deviation of the spine. Kyphosis is noted by a forward curvature of the shoulders. Arthritis is diagnosed by radiographs. Hip dysplasia is noted in older children by pain, but is usually diagnosed before the child walks by noting excessive gluteal folds and limited hip abduction.
Which of these choices contains the six elements necessary for malpractice?
- A. Causation, foreseeability, damages to the patient, a duty that was owed to the client and this duty was breached, and direct rather than indirect harm to the client.
- B. Causation, foreseeability, damages to the patient, a duty that was owed to the client and this duty was breached, and direct and/or indirect harm to the client.
- C. Causation, correlation, damages to the patient, a duty that was owed to the client and this duty was breached, and direct and/or indirect harm to the client.
- D. Causation, foreseeability, damages to the patient, a duty that was owed to the client and this duty was breached, and a medical license.
Correct Answer: A
Rationale: The six elements of malpractice are duty owed, breach of duty, foreseeability, causation, direct harm, and damages . Indirect harm or correlation are not standard elements, and a medical license is irrelevant.
When you are monitoring your client who is now started on an intravenous antibiotic for an infection, you notice that the client is exhibiting signs of anaphylaxis. What is your first priority intervention?
- A. Stop the intravenous flow
- B. Slow down the intravenous flow
- C. Notify the doctor
- D. Begin CPR
Correct Answer: A
Rationale: Stopping the IV flow immediately halts the administration of the allergen, which is the priority in anaphylaxis.