Nokea
Which nursing action is most appropriate for determining whether domestic abuse is occurring?
- A. Ask directly if domestic abuse is occurring.
- B. Arrange a second visit to validate suspicions.
- C. Assess the young children for signs of injury.
- D. Make inquiries among relatives or neighbors.
Correct Answer: A
Rationale: Directly asking about abuse in a safe, private setting encourages honest disclosure and is the most effective initial step to confirm suspicions.
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Which is the most desired outcome of a self-help group of rape victims?
- A. Obtaining mutual assistance with similar problems
- B. Receiving authoritative information about rape trauma
- C. Establishing new friendships with other victims
- D. Developing additional social skills for the future
Correct Answer: A
Rationale: Self-help groups provide mutual support, allowing victims to share experiences and coping strategies, fostering recovery through shared understanding.
The client is visibly upset pounding on the desk at the nurses’ station and shouting “You’re the nurse so you have to fix this now.” What should be the nurse’s primary rationale for recognizing that the client is a danger to staff and other clients?
- A. The client is verbally threatening the nurse to fix the situation now.
- B. The client does not acknowledge his or her role in the problem-solving process.
- C. The client has no apparent ability to recognize that he or she is acting inappropriately.
- D. The client’s main strategy for meeting personal needs and wants is intimidation and anger.
Correct Answer: D
Rationale: Intimidation and anger as primary strategies (D) indicate danger. No verbal threat (A) role acknowledgment (B) or recognition of inappropriateness (C) is evident.
Which nursing action is especially important when administering medications to a depressed client?
- A. Encouraging the client to drink a full glass of water
- B. Checking that the client has swallowed all oral medications
- C. Giving the medications on an empty stomach before meals
- D. Having the client take each medication separately
Correct Answer: B
Rationale: Ensuring medications are swallowed prevents hoarding, a risk in depressed clients with suicidal ideation.
In this situation, which nursing action is most appropriate?
- A. Placing restraints on the client's arms and legs
- B. Reassuring the client that the bugs are imaginary
- C. Reporting the behavior to the doctor to obtain a sedative order
- D. Closing the client's door so that others are not alarmed
Correct Answer: C
Rationale: Reporting delirium tremens symptoms, like hallucinations, to the physician ensures timely medical intervention for alcohol withdrawal.
The nurse is teaching home health aides about monitoring for alcohol abuse in older adults. Which response by a home health aide indicates a need for further teaching?
- A. “Alcohol abuse is the largest category of substance abuse problems in older adults.”
- B. “I should monitor more closely for alcohol abuse in single male clients who smoke.”
- C. “Retirement and freedom from work and family pressures tend to decrease alcohol use.”
- D. “Confusion malnutrition and self-neglect may be signs of alcohol abuse in the elderly.”
Correct Answer: C
Rationale: Retirement can increase alcohol use due to isolation (C is incorrect). Alcohol is a major issue (A) risk factors include male smokers (B) and signs include confusion (D).