Nokea
Which of the following substances need to be assessed when completing a family health assessment?
- A. coffee, tea, cola, and cocoa
- B. alcohol, tobacco, and illegal substances
- C. medicines prescribed by a physician
- D. all of the above
Correct Answer: D
Rationale: When assessing drug, alcohol, and tobacco practices among family members, a thorough investigation of prescribed, over-the-counter, and illegal substance-use practices should be made.
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What action should the nurse take?
- A. Reassure patient that pain is normal following surgery.
- B. Administer pm Nifedipine and assess client's response.
- C. Administer pm Meperidine HCL and assess client's response.
- D. Recheck BP and pulse rate every 20 minutes for the next hour.
Correct Answer: C
Rationale: A sinus tachycardia is a physiological response to pain. Treating the cause of the increased pulse rate requires pain medication.
The school nurse is conducting health screenings on schoolchildren. During the screening, she identifies a child with the behavioral characteristics of attention deficit disorder. Which of the following behaviors is consistent with this disorder?
- A. slow speech development
- B. overreaction to stimuli from the surroundings
- C. inability to carry on a conversation
- D. concrete thinking
Correct Answer: B
Rationale: Children with attention deficit disorder are easily distracted but are able to carry on a conversation. Concrete thinking is more indicative of age, and slow speech development has more to do with other learning disabilities.
The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:
- A. administer both medications simultaneously.
- B. give the medications sequentially, and flush well between them.
- C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug.
- D. start one medication now and begin the other medication in 2-4 hours.
Correct Answer: B
Rationale: A client with an infection needs both antibiotics as soon as possible. However, the pH of ampicillin is 8-10, and the pH of gentamicin is 3-5.5 (making them incompatible when given together). Flushing well between drugs is necessary.
An appraisal of self-care practices involves an assessment of:
- A. all diagnostic tests.
- B. home treatment practices, including nurse visits for the sick or disabled.
- C. the family's capability to get health insurance.
- D. caregiving needs and the potential for strain.
Correct Answer: D
Rationale: Short-term stressors impinging on a family include unemployment, being on welfare, the threat of termination, health, hospitalization, convalescence, depression, and suicidal thoughts. Long-term stressors impinging on the family include emotional distance, lack of communication in families (especially within marital relationships), continual geographical movement from one community to the next (so that no stable and sufficient social network is established), a spouse's minimal participation in family life, and excessive and frequent drinking bouts. Family strengths include the presence of a social support system, interest in and capability to provide child care, motivation for employment, and financial self-sufficiency, self-care beliefs, values, health-seeking behaviors, and realistic goals and limitations.
Which of the following client groups should the nurse recognize as the fastest-growing segment of the homeless population?
- A. Single, adult men
- B. Single mothers with 2 or 3 children
- C. Runaway adolescents
- D. Single, adult women
Correct Answer: B
Rationale: Single mothers with two or three children are the fastest-growing segment of the homeless population, often with young children, due to economic and social challenges.