Nursing Process Mastery Quiz RNSG 1324

Which nursing goal is appropriate for a client with multiple myeloma? 1. Achieve effective management of bone pain. 2. Recover from the disease with minimal disabilities. 3. Avoid hyperkalemia. 4. Decrease episodes of nausea and vomiting.

1. Achieve effective management of bone pain. In multiple myeloma, neoplastic plasma cells invade the bone marrow and begin to destroy the bone. As a result of this skeletal destruction, pain can be significant. There is no cure for multiple myeloma. Nausea and vomiting are not characteristics of the disease, although the client may experience anorexia. The client should be monitored for signs of hypercalcemia resulting from bone destruction, not for hyperkalemia.

The nurse is developing a plan of care for an older child who had a colostomy surgically created 6 months ago. Which nursing diagnosis is a priority for this client? 1. Impaired body image related to the colostomy 2. Fear due to loss of control of body functions 3. Pain due to surgical incision 4. Dehydration due to the colostomy

1. Impaired body image related to the colostomy An older child with a well-established colostomy would be most concerned about body image and the impact on friends and social interactions. Pain from the surgical incision should not be a concern after 6 months. The child has most likely adapted to changes in body function. Dehydration would not be an expected problem.

A client is diagnosed with dependent personality disorder. Which behavior is most likely to be evidence of Ineffective coping? 1. Inability to make choices and decisions without advice 2. Showing interest only in solitary activities 3. Avoiding developing relationships 4. Recurrent self-destructive behavior with history of depression

1. Inability to make choices and decisions without advice Individuals with dependent personality disorder typically show indecisiveness, submissiveness, and clinging behaviors so that others will make decisions for them. These clients feel helpless and uncomfortable when alone and don't show interest in solitary activities. They also pursue relationships in order to have someone to take care of them. Although clients with dependent personality disorder may become depressed and suicidal if their needs aren't met, these aren't typical responses.

A nurse is developing a drug therapy regimen that won't interfere with a client's lifestyle. When doing this, the nurse must consider the drug's: 1. adverse effects. 2. steady-state duration of action. 3. route of excretion. 4. peak concentration time.

1. adverse effects. When developing a drug therapy regimen that won't interfere with a client's lifestyle, the nurse must consider the drug's adverse effects because these may result in noncompliance. A drug's excretion route, peak concentration time, and steady-state duration of action are important considerations when developing a drug therapy regimen; however, they're related to the drug's physiologic effects and don't affect the client's lifestyle.

Which performance improvement strategy helps prevent adverse reactions to blood products? 1. Obtaining baseline vital signs 2. Confirming client identification with two qualified health professionals 3. Priming the blood administration tubing with normal saline solution 4. Instructing the client about the signs and symptoms of a blood reaction

2. Confirming client identification with two qualified health professionals The client must be correctly identified to prevent a life-threatening adverse blood reaction. Obtaining vital signs, instructing the client about the signs and symptoms of a blood reaction, and priming the blood administration tubing with normal saline solution are key steps in the blood administration procedure; however, they don't prevent adverse reactions.

A plan of care for a client with osteoporosis includes active and passive exercises, calcium supplements, and daily vitamins. What documentation by the nurse would demonstrate that effective therapy is being maintained? 1. Fewer bruises than on admission 2. Development of an increase in mobility 3. Fewer muscular spasms 4. Decreased cardiac irregularities

2. Development of an increase in mobility This plan of care will help limit bone demineralization and reduce osteoporotic pain, thus promoting increased activity. The other choices are not reflective of osteoporosis.

A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client? 1. "There is a risk for infection related to I.V. insertion." 2. "Edema and warmth are noted at I.V. insertion site." 3. "The client remains free of signs and symptoms of phlebitis." 4. "Monitor fluid intake and output every 4 hours."

3. "The client remains free of signs and symptoms of phlebitis." "The client remains free of signs and symptoms of phlebitis" is an appropriate expected outcome. Monitoring fluid intake and output is a nursing intervention. Edema and warmth are objective assessment findings. Risk for infection related to I.V. insertion is a nursing diagnosis.

When developing the plan of care for a client with suicidal ideation, developing goals to address which issue is a priority? 1. stress 2. safety 3. sleep 4. self-esteem

2. safety For the client with suicidal ideation, client safety is the priority. The nurse protects the client from self-harm or self-destruction. Although self-esteem, sleep, and stress are common areas that require intervention for a client with suicidal ideation, ensuring the client's safety is the most immediate and serious concern.

A high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome? 1. The student agrees to inform his parents of his problem. 2. The student discusses conflicts over drug use. 3. The student accepts a referral to a substance abuse counselor. 4. The student reports increased comfort with making choices.

3. The student accepts a referral to a substance abuse counselor. All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor.

A nurse works with a client diagnosed with bulimia. What is the most appropriate long-term client goal for this client? 1. Manage stresses in life without binging or purging. 2. Be able to attend college without binging or purging. 3. Be able to eat out without binging or purging. 4. Eat meals at home without binging or purging.

1. Manage stresses in life without binging or purging A successful outcome for a bulimic client is to avoid using the eating disorder as a coping measure when dealing with stress. Being able to attend college, eat at home, and eat out without binging and purging are important goals, but they do not address the primary problem of stress management and its connection to eating.

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement? 1. Related to impaired balance 2. Related to visual field deficits 3. Related to difficulty swallowing 4. Related to psychomotor seizures

1. Related to impaired balance A client with a cerebellar brain tumor may suffer injury from impaired balance as well as disturbed gait and incoordination. Visual field deficits, difficulty swallowing, and psychomotor seizures may result from dysfunction of the pituitary gland, pons, occipital lobe, parietal lobe, or temporal lobe — not from a cerebellar brain tumor. Difficulty swallowing suggests medullary dysfunction. Psychomotor seizures suggest temporal lobe dysfunction

A client with an exacerbation of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. Which nursing diagnosis requires the nurse to collaborate with other health team members to achieve the best outcome for the client? 1. Impaired gas exchange 2. Impaired skin integrity 3. Imbalanced nutrition: Less than body requirements 4. Activity intolerance

1. Impaired gas exchange Impaired gas exchange requires collaboration between the nurse, physician, and respiratory therapist to help achieve the best respiratory outcome for the client. Medications, oxygen, nebulizer treatments, and arterial blood gas analyses all require a physician's order. The respiratory therapist administers the oxygen and nebulizer treatments. The nurse assesses the client's response to medications and respiratory treatments and provides feedback to the physician and respiratory therapist. Impaired skin integrity, Activity intolerance, and Imbalanced nutrition: Less than body requirements (when applied to the client with COPD) require independent nursing interventions without collaboration with other health team members. These interventions include skin care, pacing nursing care to promote rest and minimize fatigue, and providing small, frequent meals.

During the planning step of the nursing process, the nurse: 1. establishes short- and long-term goals. 2. gathers objective data. 3. writes a statement about the client's health problem. 4. determines the client's goal achievement.

1. establishes short- and long-term goals. During the planning step of the nursing process, the nurse establishes priorities and short- and long-term goals, projects measurable outcomes, and develops a care plan. The nurse determines the client's goal achievement during the evaluation step, writes statements about the client's health problem during the nursing diagnosis step, and gathers objective data during the assessment step.

The client with hepatitis A is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. The most appropriate goal for this client is to: 1. gradually increase activity tolerance. 2. adapt to new levels of energy. 3. increase mobility. 4. learn new self-care skills.

1. gradually increase activity tolerance. The most appropriate goal for this client with hepatitis is to increase activity gradually as tolerated. Periods of alternating rest and activity should be included in the plan of care. There is no evidence that the client is physically immobile, unable to provide self-care, or needs to adapt to new energy levels.

A client is recovering from a gastric resection for peptic ulcer disease. Which outcome indicates that the goal of adequate nutritional intake is being achieved 3 weeks following surgery? The client: 1. increases food intake and tolerance gradually. 2. drinks 2,000 mL/day of water. 3. experiences a rapid weight gain within 1 week. 4. experiences occasional episodes of nausea and vomiting.

1. increases food intake and tolerance gradually. Weight gain will be slow and gradual because less food can be eaten at one time due to the decreased stomach size. More food and fluid will be tolerated as edema at the suture line decreases and healing progresses. The remaining stomach may stretch over time to accommodate more food. Nausea and vomiting can interfere with nutritional intake. Water provides hydration, but not calories and nutrients. Rapid weight gain may be due to fluid retention and would not reflect adequate nutrition.

A postmenopausal client is scheduled for a bone-density scan. The nurse should instruct the client to: 1. remove all metal objects on the day of the scan. 2. consume foods and beverages with a high content of calcium for 2 days before the test. 3. ingest 600 mg of calcium gluconate by mouth for 2 weeks before the test. 4, report any significant pain to the health care provider (HCP) at least 2 days before the test.

1. remove all metal objects on the day of the scan. Metal will interfere with the test. Metallic objects within the examination field, such as jewelry, earrings, and dental amalgams, may inhibit organ visualization and can produce unclear images. Ingesting foods and beverages days before the test will not affect bone mineral status. Short-term calcium gluconate intake will also not influence bone mineral status. The client may already have had chronic pain as a result of a bone fracture or from osteoporosis.

At the beginning of a shift, the nurse is assigned to care for four school-age children admitted that day due to an acute asthma exacerbation. Which of the following children should the nurse assess first? 1. Child with an oxygen saturation of 95% and wheezing on auscultation 2. Child with oxygen saturation of 93% and no wheezing on auscultation 3. Child whose mother reports that the child sometimes forgets to take the inhalers 4. Child with a respiratory rate of 24 breaths/minute and wheezing

2. Child with oxygen saturation of 93% and no wheezing on auscultation No wheezing on auscultation is an indication that the child is not moving air in and out and is in respiratory distress when the oxygen saturation is 93%. A respiratory rate of 24 breaths/minute in an 8-year-old child is normal. An oxygen saturation of 95% and wheezing noted on auscultation is somewhat of a concern, possibly indicating that the child needs oxygen or needs to clear the airways. However, this finding is a lower priority than no wheezing on auscultation and an oxygen saturation of 93%. The child sometimes forgetting to take medication is a concern but an oxygen saturation level of 93% is a more immediate concern.

During her first prenatal visit, a pregnant client admits to the nurse that she uses cocaine at least once per day. Which nursing diagnosis is most appropriate for this client? 1. Activity intolerance related to decreased tissue oxygenation. 2. Imbalanced nutrition: Less than body requirements related to limited food intake. 3. Impaired gas exchange related to respiratory effects of substance abuse. 4. Risk for infection related to I.V. drug use.

2. Imbalanced nutrition: Less than body requirements related to limited food intake. A substance abuser may spend more money on drugs than on food and other basic needs, leading to a nursing diagnosis of Imbalanced nutrition: Less than body requirements related to limited food intake. Activity intolerance might be a relevant nursing diagnosis if the client were having trouble sleeping or getting adequate rest; however, activity intolerance wouldn't be related to decreased tissue oxygenation in this case. If the client were an I.V. drug abuser, a diagnosis of Risk for infection related to I.V. drug use might be appropriate. Because the question doesn't specify how the client is using cocaine, a diagnosis of Impaired gas exchange related to respiratory effects of substance abuse is inappropriate.

Which nursing intervention is priority for a pregnant adolescent during her first trimester? 1. Assess the client for signs and symptoms of placenta previa 2. Refer the client to a dietitian for nutritional counseling 3. Schedule the client for a screening glucose tolerance test 4. Tell the client that she will most likely need a cesarean birth due to the head size of the fetus

2. Refer the client to a dietitian for nutritional counseling Adolescents are at risk for delivering low-birth-weight neonates. Nutritional counseling should be a priority for these clients to ensure proper fetal development. A pregnant adolescent is not likely to deliver a macrosomic neonate. The final head size of the fetus is unknown at this time. Adolescents are not at increased risk for developing gestational diabetes or placenta previa.

A nurse enters a client's room and finds a pillowcase on fire where it was placed over a table lamp. Which action should the nurse perform first? 1. Put a heavy blanket over the lamp 2. Remove the client from the room 3. Call for help 4. Use the fire extinguisher

2. Remove the client from the room The acronym RACE promotes the safest sequence of response to fire. The letters stand for Remove the client from the scene, Activate the alarm, Contain the fire, and Extinguish the blaze.

At birth, a neonate weighs 7 lb, 3 oz (3,267 g). When assessing the neonate 1 day later, the nurse obtains a weight of 7 lb (3,182 g) and an axillary temperature of 98° F (36.7° C) and notes that the sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should add which nursing diagnosis to the care plan? 1. Deficient fluid volume related to insensible fluid loss 2. Risk for injury related to hyperbilirubinemia 3. Hypothermia related to immature temperature regulation 4. Imbalanced nutrition: Less than body requirements related to inadequate feeding

2. Risk for injury related to hyperbilirubinemia Yellow sclerae indicate bilirubin deposits and possible hyperbilirubinemia. The nurse should add a diagnosis of Risk for injury related to hyperbilirubinemia to the care plan because bilirubinemia may cause bilirubin encephalopathy (kernicterus). The assessment findings don't support a nursing diagnosis of Imbalanced nutrition: Less than body requirements related to inadequate feeding because neonates normally breast-feed every 2 to 3 hours. An axillary temperature of 98° F (36.7° C) is within normal limits for a neonate, eliminating Hypothermia as a nursing diagnosis. Loss of up to 10% of birth weight is normal in neonates, making a diagnosis of Deficient fluid volume inappropriate.

The following statement appears on a client's care plan: "Client will ambulate in the hall without assistance within 4 days." This statement is an example of: 1. a nursing diagnosis. 2. a client outcome. 3. subjective data. 4. a nursing intervention.

2. a client outcome. A client outcome is a short- or long-term goal based on projected nursing interventions. A nursing diagnosis is a statement about a client's actual or potential problem. Subjective data consist of information the client has relayed to the nurse. A nursing intervention is an action the nurse takes in response to a client's

One month following a subtotal gastrectomy for cancer, the nurse is evaluating the nursing care goal related to nutrition. What indicates that the client has attained the goal? The client has: 1. resumed normal dietary intake of three meals a day. 2. achieved adequate nutritional status through oral or parenteral feedings. 3. regained weight loss. 4. controlled nausea and vomiting through regular use of antiemetics.

2. achieved adequate nutritional status through oral or parenteral feedings. An appropriate expected outcome is for the client to achieve optimal nutritional status through the use of oral feedings or total parenteral nutrition (TPN). TPN may be used to supplement oral intake, or it may be used alone if the client cannot tolerate oral feedings. The client would not be expected to regain lost weight within 1 month after surgery or to tolerate a normal dietary intake of three meals a day. Nausea and vomiting would not be considered an expected outcome of gastric surgery, and regular use of antiemetics would not be anticipated.

A client who has ulcerative colitis says to the nurse, "I cannot take this anymore; I am constantly in pain, and I cannot leave my room because I need to stay by the toilet. I do not know how to deal with this." Based on these comments, the nurse should determine the client is experiencing: 1. extreme fatigue. 2. difficulty coping. 3. a sense of isolation. 4. disturbed thought.

2. difficulty coping. It is not uncommon for clients with ulcerative colitis to become apprehensive and have difficulty coping with the frequency of stools and the presence of abdominal cramping. During these acute exacerbations, clients need emotional support and encouragement to verbalize their feelings about their chronic health concerns and assistance in developing effective coping methods. The client has not expressed feelings of fatigue or isolation or demonstrated disturbed thought processes.

Which nursing intervention is most important in preventing postoperative complications? 1. bowel and elimination monitoring 2. early ambulation 3. progressive diet planning 4. pain management

2. early ambulation Early ambulation is the most significant general nursing measure to prevent postoperative complications and has been advocated for more than 40 years. Walking the client increases vital capacity and maintains normal respiratory functioning, stimulates circulation, prevents venous stasis, improves gastrointestinal and genitourinary function, increases muscle tone, and increases wound healing. The client should maintain a healthy diet, manage pain, and have regular bowel movements. However, early ambulation is the most important intervention.

When planning the care of a client experiencing aggression, the nurse incorporates the principle of "least restrictive alternative," meaning that less restrictive interventions must be tried before more restrictive measures are employed. Which measure should the nurse consider to be the most restrictive? 1. voluntary seclusion or time-out 2. haloperidol given intramuscularly 3. tension reduction strategies 4. haloperidol given orally

2. haloperidol given intramuscularly When given intramuscularly, haloperidol is considered most restrictive because it is intrusive and a client usually does not receive the drug voluntarily. Oral haloperidol is considered less restrictive because the client usually accepts the pill voluntarily. Tension reduction strategies and voluntary seclusion are considered less restrictive because they are not intrusive and the client usually consents to their use.

A 14-year-old with rheumatic fever who is on bed rest is receiving an IV infusion of dextrose 5% r administered by an infusion pump. The nurse should verify the alarm settings on the infusion pump at which times? Select all that apply. 1. when the child moves in the bed 2. when the infusion is started 3. when the child is sleeping 4. when the child returns from X-ray 5. at the beginning of each shift

2. when the infusion is started 4. when the child returns from X-ray 5. at the beginning of each shift The alarm settings on infusion pumps should be verified at the time the infusion is started, at the beginning of each shift, and when the client is moved. The child can move in bed or sleep, but if the alarm is triggered, the nurse should verify the settings.

After talking with the nurse, a client admits to being physically abused by her husband. She says that she has never called the police because her husband has threatened to kill her if she does. She says, "I do not want to get him into trouble, because he is the father of my children. I do not know what to do!" Which nursing intervention would be most therapeutic at this time? 1. Help the client identify the behaviors that provoke the abuse. 2. Teach the client ways to reduce stress within her family. 3. Express concern for the client's safety. 4. Tell the client that she should leave her husband.

3. Express concern for the client's safety. The nurse's expression of concern for the client's safety may help the client validate her fears and choose to take action. Talking to the client about changing her behavior is a form of victim blaming and reinforces the message that the client is responsible for the abuse. She is likely getting the same message from the abuser and others. Talking to the client about reducing family stress is also a form of victim blaming. Telling the client to leave her husband is inappropriate advice. The idea of leaving the marriage may be so overwhelming that it may push the client away from the nurse as a support person.

A client is admitted to the psychiatric unit with a diagnosis of functional neurologic symptom disorder. Since witnessing a beating at gunpoint, the client is paralyzed. Which action should the nurse initially focus on when planning this client's care? 1. Exploring personal relationships that may be related to the paralysis 2. Teaching the client to deal with any limitations of the paralysis 3. Helping the client identify and verbalize his/her feelings about the incident 4. Helping the client identify any stressors or psychological conflicts

3. Helping the client identify and verbalize his/her feelings about the incident In functional neurologic symptom disorder, the client represses and converts emotional conflicts into motor, sensory, or visceral symptoms that have no physiologic cause. All of these interventions are appropriate for this client. However, the client needs first to express feelings that can help to reduce anxiety and anger, and lead to understanding and insight into the situation. The other actions are necessary, but not immediately.

A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which "related-to" phrase should the nurse add? 1. Related to tetany secondary to a decreased serum calcium level 2. Related to exhaustion secondary to an accelerated metabolic rate 3. Related to bone demineralization resulting in pathologic fractures 4. Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces

3. Related to bone demineralization resulting in pathologic fractures Poorly controlled hyperparathyroidism may cause an elevated serum calcium level. This increase, in turn, may diminish calcium stores in the bone, causing bone demineralization and setting the stage for pathologic fractures and a risk for injury. Hyperparathyroidism doesn't accelerate the metabolic rate. A decreased thyroid hormone level, not an increased parathyroid hormone level, may cause edema and dry skin secondary to fluid infiltration into the interstitial spaces. Hyperparathyroidism causes hypercalcemia, not hypocalcemia; therefore, it isn't associated with tetany.

The nurse evaluates the effectiveness of the client's postoperative plan of care. Which outcome is expected for a client with an ileal conduit? 1. The client will place an aspirin in the drainage pouch to help control odor. 2. The client demonstrates how to catheterize the stoma. 3. The client will empty the drainage pouch frequently throughout the day. 4. The client verbalizes the understanding that physical activity must be curtailed.

3. The client will empty the drainage pouch frequently throughout the day. It is important that the client empty the drainage pouch throughout the day to decrease the risk of leakage. The client does not normally need to curtail physical activity. Aspirin should never be placed in a pouch because aspirin can irritate or ulcerate the stoma. The client does not catheterize an ileal conduit stoma.

Which is an appropriate outcome for a client with rheumatoid arthritis? 1. The client will take anti-inflammatory medications as indicated by the presence of disease symptoms. 2. The client will maintain full range of motion in joints. 3. The client will manage joint pain and fatigue to perform activities of daily living. 4. The client will prevent the development of further pain and joint deformity.

3. The client will manage joint pain and fatigue to perform activities of daily living. An appropriate outcome for the client with rheumatoid arthritis is that he will adopt self-care behaviors to manage joint pain, stiffness, and fatigue and be able to perform activities of daily living. Range-of-motion (ROM) exercises can help maintain mobility, but it may not be realistic to expect the client to maintain full ROM. Depending on the disease progression, there may be further development of pain and joint deformity, even with appropriate therapy. It is important for the client to understand the importance of taking the prescribed drug therapy even if symptoms have abated.

A client who is suspicious of others, including staff, is brought to the hospital wearing a wrinkled dress with stains on the front. Assessment also reveals a flat affect, confusion, and slow movements. Which goal should the nurse identify as the initial priority when planning this client's care? 1. providing the client with clean, comfortable clothes 2. introducing the client to other clients 3. helping the client feel safe and accepted 4. giving the client information about the program.

3. helping the client feel safe and accepted The initial priority for this client is to help her overcome suspiciousness of others, including staff, and thereby feel safe and accepted. Introducing the client to others, giving the client information about the program, and providing clean clothes are important, but these are of lower priority than helping the client feel safe and accepted.

A successful real estate agent brought to the clinic after being arrested for harassing and stalking his ex-wife denies any other symptoms or problems except anger about being arrested. The ex-wife reports to the police, "He is fine except for this irrational belief that we will remarry." When collaborating with the health care provider (HCP) about a plan of care, which intervention would be most effective for the client at this time? 1. a prescription for olanzapine 10 mg daily 2. a joint session with the client and his ex-wife 3. referral to an outpatient therapist 4. a prescription for fluoxetine 20 mg every morning

3. referral to an outpatient therapist Follow-up counseling is appropriate because of the client's anger and inappropriate behaviors. The goal is to help the client deal with the end of his marriage. A joint session might have been useful before the divorce and arrest, but not after. The client is exhibiting no signs or symptoms of schizophrenia or psychosis, so olanzapine is not indicated. The client is not exhibiting signs of depression, so fluoxetine is not indicated.

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? 1. A client who ambulates in the hallway daily 2. A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago 3. A client who has an order for acetaminophen with codeine for pain but has not requested it 4. A client with a nasogastric tube

4. A client with a nasogastric tube Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.

A nurse is planning interventions for a victim of physical abuse. On what principle should the nurse base the plan? 1. A woman in crisis is unlikely to be receptive to professional help. 2. The client generally can control the batterer. 3. The victim will want to leave the abuser immediately. 4. Assessing the client's level of danger is a prerequisite to intervention.

4. Assessing the client's level of danger is a prerequisite to intervention. Assessing the client's level of danger is extremely important. The client and the children may be in serious danger if the perpetrator has threatened to kill them if they leave. Such an assessment is a prerequisite to intervention, which usually requires a multidisciplinary approach. A woman is more open to change and more receptive to professional intervention during a crisis. At other times, it is easier for her to deny the problems and maintain usual patterns of interaction. The client cannot control the batterer. She can only control her responses to the batterer and to the situation. The victim of abuse cannot be persuaded, rushed, or coerced into leaving the abuser before she is ready. This is often difficult for health care providers to understand.

The nurse develops a plan of care for a client with a t-tube. Which nursing intervention should be included? 1. Keep the t-tube clamped except during meal times. 2. Irrigate the t-tube every 4 hours to maintain patency. 3. Maintain client in a supine position while the t-tube is in place. 4. Inspect skin around the t-tube daily for irritation.

4. Inspect skin around the t-tube daily for irritation. Bile is erosive and extremely irritating to the skin. Therefore, it is essential that skin around the t-tube be kept clean and dry. T-tubes are not routinely irrigated; they are irrigated only on prescription of the health care provider. There is no need to maintain the client in a supine position; assist the client into a position of comfort. T-tubes are never clamped without a health care provider's prescription. If prescribed to be clamped, however, t-tubes are typically clamped 1 to 2 hours before and after meals.

Which nursing diagnosis takes highest priority for a client with a compound fracture? 1. Activity intolerance related to weight-bearing limitations 2. Imbalanced nutrition: Less than body requirements related to immobility 3. Impaired physical mobility related to trauma 4. Risk for infection related to effects of trauma

4. Risk for infection related to effects of trauma A compound fracture involves an opening in the skin at the fracture site. Because the skin is the body's first line of defense against infection, any skin opening places the client at risk for infection. Imbalanced nutrition: Less than body requirements is rarely associated with fractures. Although Impaired physical mobility and Activity intolerance may be associated with any fracture, these nursing diagnoses don't take precedence because they aren't as life-threatening as infection.

Which child should the nurse assess as demonstrating behaviors that need further evaluation? 1. Joey, age 2, who refuses to be toilet-trained and talks to himself 2. Adrienne, age 6, who sucks her thumb when tired and has never spent the night with a friend 3. Curt, age 10, who frequently tells his mother that he is going to run away whenever they argue 4. Stephen, age 2, who is indifferent to other children and adults and is mute

4. Stephen, age 2, who is indifferent to other children and adults and is mute Indifference to other people and mutism may be indicators of autism and would require further investigation. A 2-year-old who talks to himself and refuses to cooperate with toilet training is displaying behaviors typical for this age. Occasional thumb sucking and not having spent the night with a friend would be normal at age 6. Threatening to run away when angry is considered within the range of normal behaviors for a 10-year-old child.

Which outcome should the nurse include in the initial plan of care for a client who is exhibiting psychomotor retardation, withdrawal, minimal eye contact, and unresponsiveness to the nurse's questions? 1. The client will participate in milieu activities. 2. The client will discuss adaptive coping techniques. 3. The client will initiate interactions with peers. 4. The client will interact with the nurse.

4. The client will interact with the nurse. In the initial plan of care, the most appropriate outcome would be that the client will interact with the nurse. First, the client would begin interacting with one individual, the nurse. The nurse would gradually assist the client to engage in interactions with other clients in one-on-one contacts, progressing toward informal group gatherings and eventually taking part in structured group activities. The client needs to experience success according to the client's level of tolerance. Initiating interactions with peers occurs when the client can gain a measure of confidence and self-esteem instead of feeling intimidated or unduly anxious. Discussing adaptive coping techniques is an outcome the client may be able to reach when symptoms are not as severe and the client can concentrate on improving coping skills.