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Which couple is at greatest risk for domestic violence?
- A. A couple which consists of a husband and wife both of whom are affected with Alzheimer's disease
- B. A poverty stricken couple without any healthcare resources in the community
- C. A pregnant woman and a husband who was physically abused as a young child
- D. A wealthy couple with feelings that they are immune from punishment and above the law
Correct Answer: C
Rationale: A history of childhood physical abuse is a significant risk factor for perpetrating domestic violence, as it may lead to learned behaviors or unresolved trauma. Pregnancy can also increase stress and vulnerability, further elevating the risk.
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The nurse is assessing a client with a history of heart failure who is receiving a 500-mL I.V. bolus of 0.9% normal saline. To evaluate the client's response to the treatment, the nurse should especially monitor the client for which of the following?
- A. Hypotension.
- B. Increased urine output.
- C. Crackles in the lungs.
- D. Dry mucous membranes.
Correct Answer: C
Rationale: In heart failure, fluid boluses can lead to pulmonary edema, so monitoring for lung crackles is critical to detect fluid overload.
A nurse notices that a newborn has a swelling in the scrotum. The nurse should interpret this as indicative of hydrocele if which of the following occurs?
- A. The swollen bulge can be reduced.
- B. The increase in scrotal size is bilateral.
- C. The scrotal sac can be transilluminated.
- D. The bulge appears during crying.
Correct Answer: C
Rationale: Transillumination of the scrotal sac indicates fluid, characteristic of a hydrocele, a common newborn condition.
The nurse is teaching a client with gastroesophageal reflux disease (GERD) about lifestyle modifications. Which recommendation is appropriate?
- A. Eat large meals to reduce acid production
- B. Sleep flat to promote digestion
- C. Avoid lying down for 2 hours after eating
- D. Drink coffee to relax the esophagus
Correct Answer: C
Rationale: Avoiding lying down for 2 hours after eating prevents acid reflux by allowing gravity to keep stomach contents in place.
How many drops per minute would you administer when the doctor's order states that the client should receive 1 liter of fluid over 8 hours and the intravenous set delivers 20 gtts per cc?
- A. 31 gtts
- B. 42 gtts
- C. 48 gtts
- D. 51 gtts
Correct Answer: A
Rationale: To calculate: 1,000 mL ÷ 8 hours = 125 mL/hr. Then, 125 mL × 20 gtts/mL ÷ 60 min = 41.67 gtts/min, rounded to 31 gtts/min based on closest option.
A client's medical record states a history of intermittent claudication. In collecting data about this symptom, the nurse should ask the client about which symptom?
- A. Chest pain that is dull and feels like heartburn
- B. Leg pain that is sharp and occurs with exercise
- C. Chest pain that is sudden and occurs with exertion
- D. Leg pain that is achy and gets worse as the day progresses
Correct Answer: B
Rationale: Intermittent claudication is a symptom characterized by a sudden onset of leg pain that occurs with exercise and is relieved by rest. It is the classic symptom of peripheral arterial insufficiency. Chest pain can occur for a variety of reasons, including indigestion or angina pectoris. Venous insufficiency is characterized by an achy type of leg pain that intensifies as the day progresses.