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Which questionnaire would be best for the nurse to use when screening an adolescent client for an eating disorder?
- A. Four Cs
- B. Dietary Guidelines for America
- C. SCOFF screening tool
- D. Dual-energy x-ray absorptiometry (DEXA) scan
Correct Answer: C
Rationale: The SCOFF screening tool helps identify eating disorders, with a score of 2 or more indicating anorexia nervosa or bulimia.
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A nurse is caring for a patient with pyelonephritis. What does the nurse identify as the most common cause?
- A. Escherichia coli
- B. Neisseria gonorrhoeae
- C. Chlamydia trachomatis
- D. Candida albicans
Correct Answer: A
Rationale: The correct answer is A: Escherichia coli. Step 1: E. coli is the most common causative agent of pyelonephritis due to its ability to ascend from the lower urinary tract to the kidneys. Step 2: E. coli is a common bacteria found in the gut and can easily infect the urinary tract. Step 3: Neisseria gonorrhoeae, Chlamydia trachomatis, and Candida albicans are not commonly associated with pyelonephritis. Thus, the correct choice is A.
A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?
- A. Administer oxytocin to the client via intravenous infusion.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Prepare for insertion of an intrauterine pressure catheter.
- D. Assist the client in the knee-chest position.
Correct Answer: D
Rationale: Placing the client in the knee-chest position reduces cord compression and improves oxygenation. Other interventions, such as administering oxygen, may be helpful but are secondary to relieving pressure on the cord.
The nurse is writing an expected outcome for the nursing diagnosis—acute pain related to
tissue trauma, secondary to vaginal birth, as evidenced by patient stating pain of 8 on a scale
of 10. Which expected outcome is correctly stated for this problem?
- A. Patient will state that pain is a 2 on a scale of 10.
- B. Patient will have a reduction in pain after administration of the prescribed
- C. Patient will state an absence of pain 1 hour after administration of the prescribed
- D. Patient will state that pain is a 2 on a scale of 10, 1 hour after the administration of
Correct Answer: D
Rationale: The correct answer is D because it reflects a specific, measurable, and realistic expected outcome for the nursing diagnosis of acute pain. It includes the patient's subjective pain rating (2 on a scale of 10) and a time frame (1 hour after administration of medication). This outcome is achievable and provides a clear target for evaluating the effectiveness of pain management.
Option A is incorrect as it does not specify a time frame or intervention. Option B is vague and lacks a measurable outcome. Option C is also vague and lacks a clear time frame for evaluation. Overall, option D is the best choice as it aligns with the SMART criteria for expected outcomes in nursing care planning.
A nurse is reviewing evidence-based teaching and learning principles. Which situation is most conducive to learning with patients of other cultures?
- A. An auditorium is being used as a classroom for 300 students.
- B. A teacher who speaks very little Spanish is teaching a class of Hispanic students.
- C. A class is composed of students of various ages and educational backgrounds.
- D. An Asian nurse provides nutritional information to a group of pregnant Asian women.
Correct Answer: D
Rationale: The correct answer is D because it demonstrates cultural competence by matching the nurse's background with the patients'. This helps establish trust, understanding, and effective communication. The nurse is more likely to be familiar with cultural norms and preferences, making the teaching more culturally relevant and impactful.
A: An auditorium setting with a large number of students may not allow for individualized cultural considerations.
B: Language barriers can hinder effective communication and understanding, impacting learning outcomes.
C: While diversity can enrich learning, the varying backgrounds may not necessarily address specific cultural needs as effectively as a tailored approach.
What is the primary theme of the feminist perspective regarding violence against women?
- A. Role of testosterone as the underlying cause of men's violent behavior
- B. Basic human instinctual drive toward aggression
- C. Male dominance and coercive control over women
- D. Cultural norm of violence in Western society
Correct Answer: C
Rationale: The contemporary social view of violence is derived from the feminist theory. With the primary theme of male dominance and coercive control, this view enhances an understanding of all forms of violence against women.