Nokea
When caring for an abused client, what is most important for the nurse to do initially?
- A. Provide a safe place for the victim
- B. Refer the victim to a long-term support group
- C. Make an appointment with a counselor
- D. Make arrangements for the victim to confront the abuser
Correct Answer: A
Rationale: Providing a safe place is the priority, ensuring immediate protection from further abuse before addressing long-term support.
You may also like to solve these questions
The nurse is teaching a client how to care for a colostomy. Which factor indicates that the client needs more instruction?
- A. The client says, 'I will change the bag as soon as it gets full.'
- B. The client is observed irrigating the colostomy while sitting on the toilet.
- C. The client positions the irrigating solution container at shoulder level.
- D. The client places a chlorophyll tablet in the drainage bag.
Correct Answer: B
Rationale: Irrigating while sitting on the toilet risks contamination; irrigation should be done in a controlled setting, indicating a need for further instruction.
A client has undergone a lumbar puncture for examination of the CSF. Which of the following findings should be considered abnormal?
- A. Total protein $40 \mathrm{mg} / 100 \mathrm{~mL}$
- B. Glucose $60 \mathrm{mg} / 100 \mathrm{~mL}$
- C. Clear, colorless appearance
- D. White blood cells $100 / \mathrm{cu}$. $\mathrm{mm}$
Correct Answer: D
Rationale: Elevated white blood cells (100/cu.mm) in CSF suggest infection or inflammation, an abnormal finding. Normal protein, glucose, and clear appearance are expected.
Which of the following findings is consistent with a diagnosis of congestive heart failure?
- A. Jugular vein distention indicates increased fluid volume
- B. Carbon dioxide reading of 30
- C. Hemoglobin of 18
- D. Potassium level of 5.5
Correct Answer: A
Rationale: Jugular vein distention reflects increased fluid volume and right-sided heart failure, a hallmark of congestive heart failure. Other options are not specific to this condition.
The client is to be discharged after passing a uric acid kidney stone. This is the third time the client has been hospitalized for kidney stones. The nurse should teach the client to do which of the following?
- A. Eat generous amounts of chicken and organ meats
- B. Drink lots of water
- C. Avoid vigorous activity
- D. Take the ordered allopurinol (Zyloprim) if the symptoms recur
Correct Answer: B
Rationale: Increased fluid intake (lots of water) prevents stone formation by diluting urine. High-purine foods (meats), activity avoidance, or conditional allopurinol are incorrect.
Which client should be assigned to the licensed practical nurse?
- A. The client maintained on ventilator support
- B. The client who has a cast applied for the treatment of a fractured femur
- C. The client who has just returned from the operating room with a thyroidectomy
- D. The client receiving interferon for the treatment of hepatitis
Correct Answer: B
Rationale: A client with a cast for a fractured femur is stable and suitable for an LPN. Ventilator support and post-op thyroidectomy require RN skills, and interferon administration needs specialized knowledge.