Nokea
When assessing a client in the Emergency Department whose membranes have ruptured, the nurse notes that the fluid is a greenish color. What is the cause of this greenish coloration?
- A. blood
- B. meconium
- C. hydramnios
- D. caput
Correct Answer: B
Rationale: Greenish amniotic fluid passed when the fetus is in a cephalic (head) presentation might indicate fetal distress. A fetus in the breech presentation passes meconium due to compression on the intestinal tract.
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In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client's:
- A. feelings about what has been described
- B. thoughts about what has been described
- C. possible solutions to the problem
- D. intent in sharing the description
Correct Answer: B
Rationale: Eliciting the client's thoughts after describing issues provides insight into their perspective and interpretation, guiding further assessment. Feelings and solutions come later.
The anemias most often associated with pregnancy are:
- A. folic acid and iron deficiency.
- B. folic acid deficiency and thalassemia.
- C. iron deficiency and thalassemia.
- D. thalassemia and B12 deficiency.
Correct Answer: A
Rationale: Folic acid and iron deficiency anemia are the most common anemias, prevalent in women of childbearing age with 50% of pregnant women having this type of anemia. Iron deficiency anemia during pregnancy is a result (usually) of the increase in the plasma level during pregnancy but not in the constituent level. Also, if a woman has this type of anemia prepregnancy, it gets worse during pregnancy.
An effective intervention for a client diagnosed with Obsessive-Compulsive Disorder is:
- A. discussing the repetitive action
- B. insisting the client not perform the repetitive act
- C. informing the client that the act is not necessary
- D. encouraging daily exercise
Correct Answer: D
Rationale: Exercise reduces anxiety and redirects attention in OCD, serving as a non-confrontational intervention to decrease compulsive behaviors.
Nurses should understand the chain of infection because it refers to:
- A. the linkages between various forms of microorganisms.
- B. the sequence required for transmission of disease.
- C. the clustering of bacteria in a specific pattern.
- D. increasing virulence patterns among species of microorganisms.
Correct Answer: B
Rationale: Infection occurs in a predictable sequence requiring virulence, movement from a reservoir, and entry into a susceptible host.
An elderly client denies that abuse is occurring. Which of the following factors could be a barrier for the client to admit being a victim?
- A. knowledge that elder abuse is rare
- B. personal belief that abuse is deserved
- C. lack of developmentally appropriate screening tools
- D. fear of reprisal or further violence if the incident is reported
Correct Answer: D
Rationale: Barriers to reporting elder abuse include victim shame, fear of reprisals, fear of loss of caregiver, and lack of knowledge of agencies that provide services. Many elders fear that reporting abuse results in their placement in long-term care because the current caregiver is the abuser.