Nokea
Which of the following is not a step in primary assessment of a client presenting to the emergency department after being involved in a motor vehicle accident?
- A. Assessing and maintaining a patent airway
- B. Obtaining vital signs
- C. Using the Glasgow Coma Scale to check responsiveness
- D. Controlling bleeding
Correct Answer: B
Rationale: Primary assessment in trauma follows the ABCDE approach (Airway Breathing Circulation Disability Exposure). Obtaining vital signs is part of the secondary assessment not the primary survey which focuses on immediate life threats like airway bleeding and responsiveness.
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A family by court order undergoes treatment by a family therapist for child abuse. The nurse, who is the child's case manager knows that treatment has been effective when:
- A. The child is removed from the home and placed in foster care
- B. The child's parents identify the ways in which he is different from the rest of the family
- C. The child's father is arrested for child abuse
- D. The child's parents can identify appropriate behaviors for children in his age group
Correct Answer: D
Rationale: Removing an abused child from the home and placement in a foster home are not the desired outcome of treatment. Children who are perceived as 'different' from the rest of the family are more likely to be abused. Although legal action may be taken against abusive parents, it is not an indicator of an effective treatment program. Identification of age-appropriate behaviors is essential to the role of parents, because misunderstanding children's normal developmental needs often contributes to abuse or neglect.
Which of the following blood values would require further nursing action in a newborn who is 4 hours old?
- A. Hemoglobin 17.2 g/dL
- B. Platelets 250,000/mm3
- C. Serum glucose 30 mg/dL
- D. White blood cells 18,000/mm3
Correct Answer: C
Rationale: A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention.
Priapism may be a sign of:
- A. Altered neurological function
- B. Imminent death
- C. Urinary incontinence
- D. Reproductive dysfunction
Correct Answer: A
Rationale: Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. It is not associated with death, urinary incontinence, or reproductive dysfunction as a primary issue.
The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should:
- A. Give her a small soft blanket to hold
- B. Give her good perineal care after each diaper change
- C. Leave the door open to her room
- D. Pick her up when she cries
Correct Answer: D
Rationale: A soft blanket may be comforting, but it is not directed toward developing a sense of trust. Good perineal care is important, but it is not directed toward developing a sense of trust. An infant with meningitis needs frequent attention, but leaving the door open does not foster trust. Consistently picking her up when she cries will help the child feel trust in her caregivers.
The nurse is caring for a client with a diagnosis of gestational hypertension. Which symptom is most characteristic?
- A. Hypertension
- B. Proteinuria
- C. Fetal macrosomia
- D. Painful vaginal bleeding
Correct Answer: A
Rationale: Hypertension (BP ≥140/90) is the defining symptom of gestational hypertension. Proteinuria indicates preeclampsia and fetal macrosomia or painful bleeding are unrelated.