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Which response by the nurse would be most helpful in this situation?
- A. You should attempt to discuss the dangers of drug abuse with the patient to see if treatment is necessary.
- B. It will be necessary to get a court order before you can force your child to enter a drug treatment program.
- C. The success of the drug treatment program will depend on your child's desire to become drug-free.
- D. It's best that you force your child into the treatment program because otherwise participation probably will not occur.
Correct Answer: C
Rationale: The success of drug treatment relies on the adolescent's motivation to recover, making it important to discuss their willingness and readiness for treatment.
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Of the following methods,the safest,most precise and simplest for placental localization is:
- A. Auscultation.
- B. Ultrasonography.
- C. Radioisotope study.
- D. Abdominal palpation.
- E. Soft tissue radiography.
Correct Answer: B
Rationale: Ultrasonography is the safest most precise and simplest method for placental localization offering real-time imaging without radiation. Other methods are less accurate or involve risks.
Which finding documented by the nurse is most indicative of a client with rheumatic fever?
- A. Slow, irregular heartbeat
- B. Blotchy, diffuse erythema
- C. Decreased antistreptolysin O titer (ASO titer)
- D. Generalized migrating joint tenderness
Correct Answer: D
Rationale: Generalized migrating joint tenderness (polyarthritis) is a hallmark symptom of rheumatic fever, reflecting the inflammatory process affecting multiple joints. An elevated ASO titer (not decreased) would indicate a recent streptococcal infection, and the other options are less specific.
Which clinical manifestation of the client's full-thickness burns would the nurse detect during an assessment?
- A. Moderate level of pain due to exposed nerve endings
- B. Eschar formation throughout the area of the burn
- C. The appearance of blister formation throughout the area of the burn
- D. Noted tissue destruction extending to the subcutaneous layer
Correct Answer: D
Rationale: Full-thickness burns involve destruction of all skin layers, including the subcutaneous layer, resulting in a leathery or charred appearance. Pain is minimal due to nerve destruction, and blisters are characteristic of partial-thickness burns.
The nurse is concerned that a newborn may have congenital hydrocephalus. Which finding did the nurse likely observe on assessment?
- A. Bulging anterior fontanel
- B. Head and chest circumference equal
- C. A narrowed posterior fontanel
- D. Low-set ears
Correct Answer: A
Rationale: A bulging anterior fontanel suggests hydrocephalus due to increased intracranial pressure. Equal head/chest circumferences narrow posterior fontanel and low-set ears are normal or unrelated.
Maximum normal time for second stage of labour in primigravida without anaesthesia is about:
- A. 20 minutes.
- B. 60 minutes.
- C. 120 minutes.
- D. 240 minutes.
- E. There is no normal maximum.
Correct Answer: C
Rationale: The second stage in primigravida without anesthesia is typically up to 2 hours (120 minutes). Beyond this intervention is considered due to risks of maternal or fetal distress.