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Which of the following signs might indicate a complication during the labor process with vertex presentation?
- A. Fetal tachycardia to 170 bpm during a contraction
- B. Nausea and vomiting at 8-10 cm dilation
- C. Contraction lasting 60 seconds
- D. Appearance of dark-colored amniotic fluid
Correct Answer: D
Rationale: Fetal tachycardia may indicate fetal hypoxia; however, 170 bpm is only mild tachycardia. Nausea and vomiting occur frequently during transition and are not a complication. Contractions frequently last 60-90 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part.
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Which one of the following situations represents a maturational crisis for the family?
- A. A four-year-old entering nursery school
- B. Development of preeclampsia during pregnancy
- C. Loss of employment and health benefits
- D. Hospitalization of a grandfather with a stroke
Correct Answer: A
Rationale: A maturational crisis involves normal developmental transitions, such as a child entering nursery school, which can stress family dynamics.
A home health nurse has several elderly clients in her case load. Which of the following clients ~(is most likely to be a victim of elder abuse?
- A. A 76-year-old female with Alzheimer's dementia
- B. A 70-year-old male with diabetes mellitus
- C. A 64-year-old female with a hip replacement
- D. A 72-year-old male with Parkinson's disease
Correct Answer: A
Rationale: Elderly clients with Alzheimer's dementia are at highest risk for abuse due to cognitive impairment, dependency, and potential caregiver stress. The other conditions pose less risk.
Which client should be assigned to the nursing assistant?
- A. The 18-year-old with a fracture to two cervical vertebrae
- B. The infant with meningitis with a temperature of 101°F
- C. The elderly client with a thyroidectomy four days ago
- D. The client with a thoracotomy two days ago
Correct Answer: C
Rationale: The elderly client four days post-thyroidectomy is stable and suitable for a nursing assistant’s care (e.g., basic hygiene, ambulation). The other clients require skilled nursing due to critical conditions (cervical fracture, meningitis, recent thoracotomy).
An 80-year-old widow is living with her son and daughter-in-law. The home health nurse has been making weekly visits to draw blood for a prothrombin time test. The client is taking 5 mg of coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is suspected. Which of the following are signs of persons who are at risk for abusing an elderly person?
- A. A family member who is having marital problems and is regularly abusing alcohol
- B. A person with adequate communication and coping skills who is employed by the family
- C. A friend of the family who wants to help but is minimally competent
- D. A lifelong friend of the client who is often confused
Correct Answer: A
Rationale: This answer is correct. Two risk factors are identified in this answer. This answer is incorrect. Persons at risk tend to lack communication skills and effective coping patterns. This answer is incorrect. Persons at risk are usually family members or those reluctant to provide care. This answer is incorrect. This individual has a vested interest in providing care.
A 45-year-old client diagnosed with major depression is scheduled for electroconvulsive therapy (ECT) in the morning. Which of the following medications are routinely administered either before or during ECT?
- A. Thioridazine (Mellaril), lithium, and benztropine
- B. Atropine, sodium brevitol, and succinylcholine chloride (Anectine)
- C. Sodium, potassium, and magnesium
- D. Carbamazepine (Tegretol), haloperidol, and trihexyphenidyl (Artane)
Correct Answer: B
Rationale: Thioridazine (an antipsychotic drug), lithium (an antimanic drug), and benztropine (an antiparkinsonism agent) are generally administered to treat schizophrenic and bipolar disorders. Atropine (a cholinergic blocker), sodium brevitol (a short-acting anesthetic), and succinylcholine (a neuromuscular blocker) are administered either before or during ECT to counteract bradycardia and to provide anesthesia and total muscle relaxation. These are electrolyte substances administered to correct fluid and electrolyte imbalances in the body. Carbamazepine (an anticonvulsant), haloperidol (an antipsychotic), and trihexyphenidyl (an antiparkinsonism agent) are usually administered in psychiatric settings to control problems associated with psychotic behavior.