NUR 212 Final

A community health nurse visits a family with four children. The father behaves angrily, finds fault with a child, and asks twice, Why are you such a stupid kid? The wife says, I have difficulty disciplining the children. It's so frustrating. Which comments by the nurse will facilitate the interview with these parents? Select all that apply. a. Tell me how you punish your children. b. How do you stop your baby from crying? c. Caring for four small children must be difficult. d. Do you or your husband ever beat the children? e. Calling children stupid injures their self-esteem.

A,B,C An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by yes or no.

A person was abducted and raped at gunpoint by an unknown assailant. Which interventions should the nurse use while caring for this person in the emergency department? Select all that apply. a. Allow the person to talk at a comfortable pace. b. Pose questions in nonjudgmental, empathic ways. c. Place the person in a private room with a caregiver. d. Reassure the person that a family member will arrive as soon as possible. e. Invite family members to the examination room and involve them in taking the history. f. Put an arm around the person to offer reassurance that the nurse is caring and compassionate.

A,B,C Neutral, nonjudgmental care and emotional support are critical to crisis management for the victim of rape. The rape victim should have privacy but not be left alone. Some rape victims prefer not to have family members involved. The patients privacy may be compromised by the presence of family. The rape victims anxiety may escalate when he or she is touched by a stranger, even when the stranger is a nurse.

The nurse is admitting a child with a history of abuse. The nurse understands that the child may exhibit what behaviors that are consequences of being in an abusive environment? (Select all that apply.) a. Reliving abuse incidents b. Sleep disturbance c. Overeating d. Acting out behaviors e. Intermittent fever

A,B,D Posttraumatic stress disorder symptoms, depression symptoms, and aggression are all outcomes that children who are exposed to abuse experience. Overeating may be associated with some stressors, but it is not specifically indicative of abuse. Fever is not associated with abuse.

The nurse expects that a patient is experiencing undersecretion of adrenocortical hormones when which conditions are found upon assessment? (Select all that apply.) A. Dehydration B. Weight loss C. Steroid psychosis D. Increased potassium levels E. Increased blood glucose levels F. Decreased serum sodium levels

A,B,D,F The under secretion (hyposecretion) of adrenocortical hormones causes a condition known as Addison's disease, which is associated with decreased blood sodium and glucose levels, increased potassium levels, dehydration, and weight loss. Steroid psychosis is an effect of glucocorticoid excess.

Which serum laboratory values alert the nurse to the possibility of hyperaldosteronism? (Select all that apply.) a. Sodium, 150 mEq/L b. Sodium, 130 mEq/L c. Potassium, 2.5 mEq/L d. Potassium, 5.0 mEq/L e. pH, 7.28 f. pH, 7.50

A,C,E Aldosterone increases reabsorption of sodium and excretion of potassium. Hyperaldosteronism causes hypernatremia, hypokalemia, and metabolic alkalosis. The other values are not indicative of hyperaldosteronism.

the nurse is teaching nursing students about assessment clues to genetic disorders in the newborn. Which should the nurse include in the teaching session? (Select all that apply.) a. Low-set ears b. Mongolian spots c. Epicanthal folds d. Cephalohematoma e. Forehead prominence

A,C,E Assessment clues to genetic disorders in the newborn include low-set ears, epicanthal folds, and forehead prominence. Mongolian spots and cephalohematoma are findings in a newborn that are not indicative of a genetic disorder.

A nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members should the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) a. Registered dietitian b. Nursing assistant c. Clinical pharmacist d. Certified herbalist e. Health care provider

A,C,E Clients who are prescribed NPO while experiencing an acute pancreatitis episode may need enteral or parenteral nutrition. The nurse should collaborate with the registered dietitian, clinical pharmacist, and health care providers to plan and implement the more appropriate nutritional interventions. The nursing assistant and certified herbalist would not assist with this clinical decision.

The nurse is teaching parents of preschool-aged children strategies to prevent sexual abuse. What should the nurse include in the teaching session? (Select all that apply.) a. Back up a child's right to say no. b. Don't take what your child says too seriously. c. Take a second look at signals of potential danger. d. Dont be too detailed about examples of sexual assault. e. Remind children that even nice people sometimes do mean things.

A,C,E To provide protection and preparation from sexual abuse, parents should back up a childs right to say no, take a second look at signals of potential danger, and remind children that even nice people sometimes do mean things. Parents should take what children say seriously and they should give specific definitions and examples of sexual assault.

Match the key genetic terms to their definitions. a. Concordant - A condition in which two individuals have the same genetic trait b. Congenital - Present at birth c. Cytogenetics - Study of chromosomes, with special focus on chromosome abnormalities d. Genome - Complete genetic information of an organism e. Teratogen - An environmental agent capable of producing a birth defect 1. Study of chromosomes, with special focus on chromosome abnormalities 2. Complete genetic information of an organism 3. A condition in which two individuals have the same genetic trait 4. Present at birth 5. An environmental agent capable of producing a birth defect

A=3 B=4 C=1 D=2 E=5

A nurse collaborates with unlicensed assistive personnel (UAP) to provide care for a client who is in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should the nurse include when delegating care for this client? (Select all that apply.) a. Do not allow the client to eat between meals. b. Make sure the client receives a protein shake. c. Do not allow caffeine-containing beverages. d. Make sure the foods are bland with little spice. e. Do not allow high-carbohydrate food items.

B,C,D During the healing phase of pancreatitis, the client should be provided small, frequent, moderate- to high-carbohydrate, high-protein, low-fat meals. Protein shakes can be provided to supplement the diet. Foods and beverages should not contain caffeine and should be bland.

The nurse is caring for a client after a Whipple procedure. Which manifestations might indicate that a complication from the operation has occurred? (Select all that apply.) a. Urinary retention b. Substernal chest pain c. Shortness of breath d. Lack of bowel sounds or flatus e. Urine output of 20 mL/6 hr

B,C,D,E Myocardial infarction (chest pain), pulmonary embolism (shortness of breath), adynamic ileus (lack of bowel sounds or flatus), and renal failure (urine output of 20 mL/6 hr) are just some of the complications that the nurse must monitor the client for after the Whipple procedure. Urinary retention is not a complication of this operation.

The nurse is reviewing the characteristics of autosomal dominant inheritance. Which are true about these characteristics? (Select all that apply.) a. A carrier state exists. b. The phenotype appears in consecutive generations. c. Males and females are equally likely to be affected. d. Parents who have affected children are usually asymptomatic. e. Children of an affected parent have a 50% chance of being affected.

B,C,E Characteristics of autosomal dominant inheritance include the phenotype appears in consecutive generations, males and females are equally affected, and children of an affected parent have a 50% chance of being affected. A carrier state and parents who have affected children are usually asymptomatic are characteristic of autosomal recessive inheritance.

What identified characteristics occur more frequently in parents who abuse their children? (Select all that apply.) a. Older parents b. Socially isolated c. Middle class parents d. Single-parent families e. Few supportive relationships

B,D,E Abusive families are often socially isolated and have few supportive relationships. Single-parent families are at higher risk for abuse. Younger parents more often are abusers of their children. Abusive parents have stressors such as low-income circumstances, with little education, and are not middle class parents.

The nurse is interviewing a prenatal client about specific risk factors that are indications for prenatal testing. Which specific risk factors should the nurse note? (Select all that apply.) a. Previous twins b. Inherited disorder c. Previous preterm birth d. Cytomegalovirus infection e. Previous stillbirth or neonatal death

B,D,E Specific risk factors that are indications for prenatal testing include inherited disorder, cytomegalovirus infection (teratogenic infection), and previous stillbirth or neonatal death. Previous twins or previous preterm birth are not specific risk factors that are indications for prenatal testing.

A nurse teaches a client who is recovering from acute pancreatitis. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Take a 20-minute walk at least 5 days each week. b. Attend local Alcoholics Anonymous (AA) meetings weekly. c. Choose whole grains rather than foods with simple sugars. d. Use cooking spray when you cook rather than margarine or butter. e. Stay away from milk and dairy products that contain lactose. f. We can talk to your doctor about a prescription for nicotine patches.

B,D,F The client should be advised to stay sober, and AA is a great resource. The client requires a low-fat diet, and cooking spray is low in fat compared with butter or margarine. If the client smokes, he or she must stop because nicotine can precipitate an exacerbation. A nicotine patch may help the client quit smoking. The client must rest until his or her strength returns. The client requires high carbohydrates and calories for healing; complex carbohydrates are not preferred over simple ones. Dairy products do not cause a problem.

Which can be directly attributed to a single-gene disorder? (Select all that apply.) a. Cleft lip b. Cystic fibrosis c. Turner syndrome d. Klinefelter syndrome e. Neurofibromatosis

B,E Cystic fibrosis is a single-gene disorder inherited as an autosomal recessive trait, and neurofibromatosis is a single-gene disorder inherited as an autosomal dominant trait. Cleft lip is classified as a multifactorial disorder in which a genetic susceptibility and appropriate environment appear to play important roles. Turner and Klinefelter syndromes are disorders of sex chromosome number.

A patient is taking fludrocortisone (Florinef) for Addison's disease, and his wife is concerned about all of the problems that may occur with this therapy. When teaching them about therapy with this drug, the nurse will include which information? A. It may cause severe postural hypotension. B. It needs to be taken with food or milk to minimize gastrointestinal upset. C. The medication needs to be stopped immediately if nausea or vomiting occurs. D. Weight gain of 5 pounds or more in 1 week is an expected adverse effect.

B. It needs to be taken with food or milk to minimize gastrointestinal upset. Patients receiving fludrocortisone need to take it with food or milk to minimize gastrointestinal upset; weight gain of 5 pounds or more in 1 week needs to be reported to the physician; abrupt withdrawal is not recommended because it may precipitate an adrenal crisis. Adverse effects are related to the fluid retention and may include heart failure and hypertension.

The admission note indicates a patient diagnosed with major depressive disorder has anergia and anhedonia. For which measures should the nurse plan? Select all that apply. a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

C,D,E Anhedonia refers to the inability to find pleasure or meaning in life; thus planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness. Anergia is the lack of energy, not excessive energy. Anhedonia does not necessarily imply the presence of guilty ruminations.

Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse? The child who has: a. repeated middle ear infections. b. severe colic. C. bite marks. D. croup.

C. bite marks. Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, colic, and croup are not problems induced by violence.

A patient was started on escitalopram (Lexapro) 5 days ago and now says, This medicine isn't working. The nurses best intervention would be to: a. discuss with the health care provider the need to change medications. b. reassure the patient that the medication will be effective soon. C. explain the time lag before antidepressants relieve symptoms. D. critically assess the patient for symptom relief.

C. explain the time lag before antidepressants relieve symptoms. Escitalopram is an SSRI antidepressant. Between 1 and 3 weeks of treatment are usually necessary before a relief of symptoms occurs. This information is important to share with patients.

When working with rape victims, immediate care focuses first on: a. collecting evidence. b. notifying law enforcement. C. helping the victim feel safe. D. documenting the victims comments.

C. helping the victim feel safe. The first focus of care is helping the victim feel safe. An already vulnerable individual may view assessment questions and the physical procedures as intrusive violations of privacy and even physically threatening. The patient might decline to have evidence collected or to involve law enforcement.

Turner syndrome is suspected in an adolescent girl with short stature. What causes this? a. Absence of one of the X chromosomes b. Presence of an incomplete Y chromosome c. Precocious puberty in an otherwise healthy child d. Excess production of both androgens and estrogens

a. Absence of one of the X chromosomes Turner syndrome is caused by an absence of one of the X chromosomes. Most girls who have this disorder have one X chromosome missing from all cells. No Y chromosome is present in individuals with Turner syndrome. These young women have 45 rather than 46 chromosomes.

Parents ask the nurse about the characteristics of autosomal recessive inheritance. Which is characteristic of autosomal recessive inheritance? a. Affected individuals have unaffected parents. b. Affected individuals have one affected parent. c. Affected parents have a 50% chance of having an affected child. d. Affected parents will have unaffected children.

a. Affected individuals have unaffected parents. Parents who are carriers of a recessive gene are asymptomatic. For a child to be affected, both parents must have a copy of the gene, which is passed to the child. Both parents are asymptomatic but can have affected children. In autosomal recessive inheritance, there is a 25% chance that each pregnancy will result in an affected child. In autosomal dominant inheritance, affected parents can have unaffected children.

The postanesthesia care unit nurse is caring for a client who has just undergone an open Whipple procedure. The client has multiple tubes and drains in place after the surgery. Which does the nurse assess first? a. Endotracheal tube with 40% fraction of inspired oxygen (FiO2) b. Foley catheter to bedside drainage c. Nasogastric tube to low intermittent suction d. Triple-lumen IV catheter with lactated Ringer's solution

a. Endotracheal tube with 40% fraction of inspired oxygen (FiO2) Using the ABCs, airway and oxygenation status should always be assessed first. Next, the nurse should assess the IV line (circulation). After that, the other two items can be assessed.

A child with hemophilia A is scheduled for surgery. What precautions should the nurse institute with this child? a. Handle the child gently when transferring to a cart. b. Caution the child not to brush his teeth before surgery. c. Use tape sparingly on postoperative dressings. d. Do not administer analgesics before surgery.

a. Handle the child gently when transferring to a cart. The goal of prevention of bleeding episodes is directed toward decreasing the risk of injury. The child should be handled carefully when transferring to a cart. Brushing teeth, use of tape, and giving analgesics will not risk a bleeding episode.

The inheritance of which is X-linked recessive? a. Hemophilia A b. Marfan syndrome c. Neurofibromatosis d. Fragile X syndrome

a. Hemophilia A Hemophilia A is inherited as an X-linked recessive trait. Marfan syndrome and neurofibromatosis are inherited as autosomal dominant disorders. Fragile X is inherited as an X-linked trait.

A client is hospitalized with acute pancreatitis. The nursing assistant reports to the nurse that when a blood pressure cuff was applied, the clients hand had a spasm. Which additional finding does the nurse correlate with this condition? a. Serum calcium, 5.8 mg/dL b. Serum sodium, 166 mEq/L c. Serum creatinine, 0.9 mg/dL d. Serum potassium, 4.2 mEq/dL

a. Serum calcium, 5.8 mg/dL Spasm of the hand when a blood pressure cuff is applied (Trousseau's sign) is indicative of hypocalcemia. The clients calcium level is low. The sodium level is high, but that is not related to Trousseau's sign. Creatinine and potassium levels are normal.

Which is a birth defect or disorder that occurs as a new case in a family and is not inherited? a. Sporadic b. Polygenic c. Monosomy d. Association

a. Sporadic Sporadic describes a birth defect previously unidentified in a family. It is not inherited. Polygenic inheritance involves the inheritance of many genes at separate loci whose combined effects produce a given phenotype. Monosomy is an abnormal number of chromosomes whereby the chromosome is represented by a single copy in a somatic cell. A nonrandom cluster of malformations without a specific cause is an association.

A client is brought to the emergency department via rescue squad in acute adrenal crisis. Which action by the nurse is the priority? a. Start an IV line if the client does not already have one. b. Administer hydrocortisone sodium succinate (Solu-Cortef). c. Instruct the nursing assistant to check the client's blood glucose. d. Administer 20 units of insulin and 20 mg of dextrose in normal saline.

a. Start an IV line if the client does not already have one. All actions are appropriate for the client with adrenal crisis. However, therapy is given IV, so the priority is to establish IV access. Solu-Cortef is the drug of choice. Blood glucose is monitored hourly and treatment is provided as needed. Insulin and dextrose are used to treat any hyperkalemia.

A couple expecting their first child has a positive family history for several congenital defects and disorders. The couple tells the nurse that they are opposed to abortion for religious reasons. Which should the nurse consider when counseling the couple? a. The couple should be encouraged to have recommended diagnostic testing. b. The couple needs counseling regarding advantages and disadvantages of pregnancy termination. c. Diagnostic testing is required by law in this situation. d. Diagnostic testing is of limited value if termination of pregnancy is not an option.

a. The couple should be encouraged to have recommended diagnostic testing. The benefits of prenatal diagnostic testing extend beyond decisions concerning abortion. If the child has congenital disorders, decisions can be made about fetal surgery if indicated. In addition, if the child is expected to require neonatal intensive care at birth, the mother is encouraged to deliver at a level III neonatal center. The couple is counseled about the advantages and disadvantages of prenatal diagnosis, not pregnancy termination, although the family cannot be forced to have prenatal testing. The information gives the parents time to grieve and plan for their child if congenital disorders are present. If the child is free of defects, then the parents are relieved of a major worry.

A couple has given birth to their first child, a boy with a recessive disorder. The genetic counselor tells them that the risk of recurrence is one in four. Which statement is a correct interpretation of this information? a. The risk factor remains the same for each pregnancy. b. The risk factor will change when they have a second child. c. Because the parents have one affected child, the next three children should be unaffected. d. Because the parents have one affected child, the next child is four times more likely to be affected.

a. The risk factor remains the same for each pregnancy. Each pregnancy has the same risks for an affected child. Because an odds ratio reflects the risk, this does not change over time. The statement by the genetic counselor refers to a probability. This does not change over time. The statement Because the parents have one affected child, the next child is four times more likely to be affected does not reflect autosomal recessive inheritance.

relationship that is indicative of abuse. Being the firstborn or the same gender as the abuser is not linked to child abuse. Avoidance of favoritism is not usually a cause of abuse. What statement is correct about young children who report sexual abuse? a. They may exhibit various behavioral manifestations. b. In more than half the cases, the child has fabricated the story. c. Their stories should not be believed unless other evidence is apparent. d. They should be able to retell the story the same way to another person.

a. They may exhibit various behavioral manifestations. Victims of sexual abuse have no typical profile. The child may exhibit various behavioral manifestations, none of which is diagnostic for sexual abuse. When children report potentially sexually abusive experiences, their reports need to be taken seriously. Other children in the household also need to be evaluated. In children who are sexually abused, it is often difficult to identify other evidence. In one study, approximately 96% of children who were sexually abused had normal genital and anal findings. The ability to retell the story is partly dependent on the child's cognitive level. Children who repeatedly tell identical stories may have been coached.

A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the victim says softly, I will never be the same again. I can't face my friends. There is no sense of trying to go on. Select the nurses most important response. a. Are you thinking of suicide? b. It will take time, but you will feel the same as before. c. Your friends will understand when you tell them. d. You will be able to find meaning in this experience as time goes on.

a. Are you thinking of suicide? The victims words suggest hopelessness. Whenever hopelessness is present, so is the risk for suicide. The nurse should directly address the possibility of suicidal ideation with the victim. The other options attempt to offer reassurance before making an assessment.

A person was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the person is in the acute phase of rape trauma syndrome? a. Confusion and disbelief b. Decreased motor activity c. Flashbacks and dreams d. Fears and phobias

a. Confusion and disbelief Shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity depict the acute phase of rape trauma syndrome. Flashbacks, dreams, fears, and phobias occur in the long-term reorganization phase of rape trauma syndrome. Decreased motor activity, by itself, is not indicative of any particular phase.

An older adult diagnosed with Alzheimer's disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Dementia b. Living in a rural area c. Being part of a busy family d. Being home only in the evening

a. Dementia Older adults, particularly those with cognitive impairments, are at high risk for abuse. The other characteristics are not identified as placing an individual at high risk for abuse.

A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge? a. Do you have a one- or two-story home? b. Can you check your own pulse rate? c. Do you have any alcohol in your home? d. Can you prepare your own meals?

a. Do you have a one- or two-story home? A client recovering from chronic pancreatitis should be limited to one floor until strength and activity increase. The client will need a bathroom on the same floor for frequent defecation. Assessing pulse rate and preparation of meals is not specific to chronic pancreatitis. Although the client should be encouraged to stop drinking alcoholic beverages, asking about alcohol availability is not adequate to assess this clients safety.

Which is an effective nursing intervention to assist an angry patient to learn to manage anger without violence? a. Help the patient identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking. b. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present. c. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings. d. Administer an antipsychotic or anti anxiety medication when the patient feels angry.

a. Help the patient identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking. Anger has a strong cognitive component; therefore, using cognition to manage anger is logical. The incorrect options do nothing to help the patient learn anger management.

A patient tells the nurse, My husband is abusive most often when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me. What risk factor was most predictive for the husband to become abusive? a. History of family violence b. Loss of employment c. Abuse of alcohol d. Poverty

a. History of family violence An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive.

A patient at the emergency department is diagnosed with a concussion. The patient is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Risk of intimate partner violence b. Phobia of crowded places c. Migraine headaches d. Major depression

a. Risk of intimate partner violence The diagnosis of a concussion suggests violence as a cause. The patient is exhibiting indicators of abuse including fearfulness, depressed affect, poor eye contact, and a possessive spouse. The patient may also be experiencing depression, anxiety, and migraine headaches, but the nurses advocacy role necessitates an assessment for intimate partner violence.

An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the persons underclothes. The priority actions of staff members should focus on: a. maintaining the airway. b. preserving rape evidence. c. obtaining a description of the rape. D. determining what drug was ingested.

a. maintaining the airway. Because the patient is unconscious, the risk for airway obstruction is present. The incorrect options are of lower priority than preserving physiologic functioning.

A nurse caring for a patient taking a serotonin reuptake inhibitor (SSRI) will develop outcome criteria related to: a. mood improvement. b. logical thought processes. C. reduced levels of motor activity. D. decreased extrapyramidal symptoms.

a. mood improvement. SSRIs affect mood, relieving depression in many patients. SSRIs do not act to reduce thought disorders. SSRIs reduce depression but have little effect on motor hyperactivity. SSRIs do not produce extrapyramidal symptoms.

A nurse is caring for a patient in the emergency department who has been a victim of intimate partner violence. What is most important for the nurse to include in the plan of care? a. Medication to calm the perpetrator of the violence b. A list of community resources c. A referral for self-defense training d. A referral to the victims religious advisor

b. A list of community resources Providing education that will address immediate safety needs for the patient is a priority action for the nurse. The nurse is not creating a plan for the perpetrator, nor is it the responsibility of the victim to receive medication for another person. Self-defense training does not meet the immediate safety concern for the patient and may aggravate the perpetrator further. Accessing support from a religious advisor is good for ongoing support, but it does not address the immediate need for safety information.

Which is characteristic of X-linked recessive inheritance? a. There are no carriers. b. Affected individuals are principally males. c. Affected individuals are principally females. d. Affected individuals will always have affected parents.

b. Affected individuals are principally males. In X-linked recessive disorders, the affected individuals are usually male. With recessive traits, usually two copies of the gene are needed to produce the effect. Because the male has only one X chromosome, the effect is visible with only one copy of the gene. Females are usually only carriers of X-linked recessive disorders. The X chromosome that does not have the recessive gene will produce the normal protein, so the woman will not show evidence of the disorder. The transmission is from mother to son. Usually the mother and father are unaffected.

The nurse is caring for a client who has undergone surgery to drain a pancreatic pseudocyst with placement of a pancreatic drainage tube. Which nursing intervention prevents complications from this procedure? a. Positioning the client in a right side-lying position b. Applying a skin barrier around the drainage tube site c. Clamping the drainage tube for 2 hours every 12 hours d. Irrigating the drainage tube daily with 30 mL of sterile normal saline

b. Applying a skin barrier around the drainage tube site The nurse assesses the skin around the drainage tube for redness or skin irritation, which can be severe from leakage of pancreatic enzymes. The nurse applies a skin barrier such as Stomahesive around the drainage tube to prevent excoriation. A side-lying position may be more comfortable for the client. The drainage tube should not be clamped or irrigated without specific orders.

Which genetic term refers to a person who possesses one copy of the affected gene and one copy of an unaffected gene and is clinically unaffected? a. Allele b. Carrier c. Pedigree d. Multifactorial

b. Carrier An individual who is a carrier is asymptomatic but possesses a genetic alteration, either in the form of a gene or chromosome change. Alleles are alternative expressions of genes at a different locus. A pedigree is a diagram that describes family relationships, gender, disease, status, or other relevant information about a family. Multifactorial describes a complex interaction of both genetic and environmental factors that produce an effect on the individual.

What is the most common form of child maltreatment? a. Sexual abuse b. Child neglect c. Physical abuse d. Emotional abuse

b. Child neglect Child neglect, which is characterized by the failure to provide for the child's basic needs, is the most common form of child maltreatment. Sexual abuse, physical abuse, and emotional abuse are individually not as common as neglect.

A severely depressed patient cannot state any positive attributes to his or her life. The nurse patiently sits with this patient and assists the patient to identify several activities the patient is actually looking forward to in life. The nurse is helping the patient to demonstrate which spiritual concept? a. Time management b. Hope c. Charity d. Faith

b. Hope The concept of hope is vital to nursing; it enables a person to anticipate positive experiences. Being patient and friendly and creating positive relationships are key concepts in all areas of nursing, but especially with depressed patients. The nurses actions do not address time management, charity, or faith.

A child has been found to have a deficiency in 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase. Which condition is this child at risk for? a. Increased uric acid b. Hypercholesterolemia c. Increased phenylketones d. Altered oxygen transport

b. Hypercholesterolemia HMG-CoA leads to a disruption of metabolic feedback mechanism and accumulation of end product (cholesterol) with the resulting condition of hypercholesterolemia.

A child with Prader-Willi syndrome has been hospitalized. Which assessment findings does the nurse expect with this syndrome? a. Nonverbal b. Insatiable hunger c. Abnormal, puppet like gait d. Paroxysms of inappropriate laughter

b. Insatiable hunger Prader-Willi syndrome is characterized by insatiable hunger that can lead to morbid obesity in childhood. Abnormal, puppet like gait, paroxysms of inappropriate laughter, and nonverbal are characteristics seen in Angelman syndrome.

Which dietary alterations does the nurse make for a client with Cushing's disease? a. High carbohydrate, low potassium b. Low carbohydrate, low sodium c. Low protein, low calcium d. High carbohydrate, low potassium

b. Low carbohydrate, low sodium The client with Cushing's disease has weight gain, muscle loss, hyperglycemia, and sodium retention. Dietary modifications need to include reduction of total calories and carbohydrates to prevent or reduce the degree of hyperglycemia. Sodium retention causes water retention and hypertension. Clients are encouraged to restrict their sodium intake moderately. Clients often have bone density loss and need more calcium.

The nurse is assessing a neonate who was born 1 hour ago to healthy white parents in their early forties. Which finding should be most suggestive of Down syndrome? a. Hypertonia b. Low-set ears c. Micrognathia d. Long, thin fingers and toes

b. Low-set ears Children with Down syndrome have low-set ears. Infants with Down syndrome have hypotonia, not hypertonia. Micrognathia is common in trisomy 16, not Down syndrome. Children with Down syndrome have short hands with broad fingers.

A hospitalized school-age child with phenylketonuria (PKU) is choosing foods from the hospital menu. Which food choice should the nurse discourage the child from choosing? a. Banana b. Milkshake c. Fruit juice d. Corn on the cob

b. Milkshake Foods with low phenylalanine levels (e.g., some vegetables [except legumes]; fruits; juices; and some cereals, breads, and starches) must be measured to provide the prescribed amount of phenylalanine. Most high-protein foods, such as meat and dairy products, are either eliminated or restricted to small amounts.

A man is hospitalized after surgery that amputated both lower extremities owing to injuries sustained during military service. The nurse should recognize his need to grieve for what type of loss? a. Maturational loss b. Situational loss c. Perceived loss d. Uncomplicated loss

b. Situational loss Loss of a body part from injury is a situational loss. Maturational losses occur as part of normal life transitions. Perceived loss is not obvious to other people. Uncomplicated is not a type of loss; it is a description of normal grief.

Critical Thinking: A crisis intervention nurse is training emergency department staff on treatment needs of persons in abusive relationships. What is a common difficulty staff encounter when caring for this population? a. There is not a good legal pathway to help persons in abusive relationships. b. The abused person may return to the abusive home setting. c. Hospital policies do not identify the legal care needed for abused persons. d. Because length of care is short in the emergency department, there is little staff can do for patients who have been abused.

b. The abused person may return to the abusive home setting. Abused persons return to abusive settings because they feel they have no other options or they fear reprisal from the abusive partner. There are policies in all healthcare facilities that describe the legal needs and the legal process that needs to be followed when caring for abused patients. Even in short-stay care settings there are interventions that can be helpful to a patient who has experienced abuse.

A newborn in the neonatal intensive care unit (NICU) is dying as a result of a massive infection. The parents speak to the neonatologist, who informs them of their sons prognosis. When the father sees his son, he says, He looks just fine to me. I can't understand what all this is about. What is the most appropriate response or reaction by the nurse at this time? a. Didn't the physician tell you about your sons problems? b. This must be a difficult time for you. Tell me how you're doing. c. Quietly stand beside the infant's father. d. You'll have to face up to the fact that he is going to die sooner or later.

b. This must be a difficult time for you. Tell me how you're doing. The phase of intense grief can be very difficult, especially for fathers. Parents should be encouraged to share their feelings during the initial steps in the grieving process. This father is in a phase of acute distress and is reaching out to the nurse as a source of direction in his grieving process. Shifting the focus is not in the best interest of the parent. Nursing actions may help the parents actualize the loss of their infant through a sharing and verbalization of their feelings of grief. Telling the father that his son is going to die sooner or later is dispassionate and an inappropriate statement on the part of the nurse.

Which abnormality is a common sex chromosome defect? a. Down syndrome b. Turner syndrome c. Marfan syndrome d. Hemophilia

b. Turner syndrome Turner syndrome is caused by an absence of one of the X chromosomes. Down syndrome is caused by trisomy 21 (three copies rather than two copies of chromosome 21). Marfan syndrome is a connective tissue disorder inherited in an autosomal dominant pattern. Hemophilia is a disorder of blood coagulation inherited in an X-linked recessive pattern.

The nurse is caring for a client with chronic pancreatitis. Which instruction by the nurse is most appropriate? a. You will need to limit your protein intake. b. We need to call the dietitian to get help in planning your diet. c. You cannot eat concentrated sweets any longer. d. Try to eat less red meat and more chicken and fish.

b. We need to call the dietitian to get help in planning your diet. A client with chronic pancreatitis needs 4000 to 6000 calories per day for optimum nutrition and healing. The client may have additional restrictions if he or she has other health problems such as diabetes. The nurse should collaborate with the registered dietitian to help the client plan nutritional intake.

A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, I want to go to school, but we can't afford a babysitter. It doesnt matter; Im too dumb to learn. What preliminary assessment is evident? a. Insufficient data are present to make an assessment. b. Child and siblings are experiencing neglect. c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse.

b. Child and siblings are experiencing neglect. child is experiencing neglect when the parents take away the opportunity to attend school. The other children may also be experiencing physical neglect, but more data should be gathered before making the actual assessment. The information presented does not indicate a high risk for sexual abuse, and no concrete evidence of physical abuse is present.

A clinic nurse interviews an adult patient who reports fatigue, back pain, headaches, and sleep disturbances. The patient seems tense and then becomes reluctant to provide more information and hurries to leave. How can the nurse best serve the patient? a. Explore the possibility of patient social isolation. b. Have the patient complete an abuse assessment screen. c. Ask whether the patient has ever had psychiatric counseling. d. Ask the patient to disrobe; then assess for signs of physical abuse.

b. Have the patient complete an abuse assessment screen. In this situation, the nurse should consider the possibility that the patient is a victim of intimate partner violence. Although the patient is reluctant to discuss issues, he or she may be willing to fill out an abuse assessment screen, which would then open the door to discussion.

A nurse working in the county jail interviews a man who recently committed a violent sexual assault against a woman. Which comment from this perpetrator is most likely? a. She was very beautiful. b. I gave her what she wanted. c. I have issues with my mother. d. I've been depressed for a long time.

b. I gave her what she wanted. Rape involves a need for control, power, degradation, and dominance over others. The correct response shows a lack of remorse or guilt, which is a common characteristic of an antisocial personality. The incorrect responses show an appreciation for women, psychological conflict, and self-disclosure, which are not expected from a perpetrator of sexual assault.

A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this client's plan of care to reduce discomfort? a. Administer morphine sulfate intravenously every 4 hours as needed. b. Maintain nothing by mouth (NPO) and administer intravenous fluids. c. Provide small, frequent feedings with no concentrated sweets. d. Place the client in semi-Fowler's position with the head of the bed elevated.

b. Maintain nothing by mouth (NPO) and administer intravenous fluids. The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production. IV fluids should be used to prevent dehydration. The client may need a nasogastric tube. Pain medications should be given around the clock and more frequently than every 4 to 6 hours. A fetal position with legs drawn up to the chest will promote comfort.

After treatment for a detached retina, a victim of intimate partner violence says, My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me. Which nursing diagnosis applies? a. Social isolation, related to lack of community support system b. Risk for injury, related to partners physical abuse when intoxicated c. Deficient knowledge, related to resources for escape from the abusive relationship d. Disabled family coping, related to uneven distribution of power within a relationship

b. Risk for injury, related to partners physical abuse when intoxicated Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The episodes are likely to become increasingly violent. Data are not present that show social isolation or disabled family coping, although both are common among victims of violence. Deficient knowledge does not apply to this patients use of defense mechanisms.

A patient diagnosed with major depressive disorder repeatedly tells staff members, I have cancer. Its my punishment for being a bad person. Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. a. Powerlessness b. Risk for suicide c. Stress overload d. Spiritual distress

b. Risk for suicide A patient with depression who feels so worthless as to believe cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses listed.

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness protects one's own mental health. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to involvement with the victim. d. Positive feelings promote the development of sympathy for patients.

b. Strong negative feelings interfere with assessment and judgment. Strong negative feelings cloud the nurses judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny personal feelings. Strong positive feelings lead to overinvolvement with the victim.

A priority nursing intervention for a patient diagnosed with major depressive disorder is: a. distracting the patient from self-absorption. b. carefully and inconspicuously observing the patient around the clock. C. allowing the patient to spend long periods alone in self-reflection. D. offering opportunities for the patient to assume a leadership role in the therapeutic milieu.

b. carefully and inconspicuously observing the patient around the clock. Approximately two thirds of people with depression contemplate suicide. Patients with depression who exhibit feelings of worthlessness are at higher risk. Regularly planned observations of the patient with depression may prevent a suicide attempt on the unit.

A patient is hospitalized for major depressive disorder. Of the medications listed, a nurse can expect to provide the patient with teaching about: a. chlordiazepoxide (Librium). b. fluoxetine (Prozac). C. clozapine (Clozaril). D. tacrine (Cognex).

b. fluoxetine (Prozac). Fluoxetine is a selective serotonin reuptake inhibitor (SSRI), an antidepressant that blocks the reuptake of serotonin with few anticholinergic and sedating side effects; clozapine (Clozaril) is an antipsychotic medication; chlordiazepoxide (Librium) is an anxiolytic drug; and tacrine (Cognex) is used to treat Alzheimer disease.

Which assessment finding presents the greatest risk for violent behavior? A patient who: a. is severely agoraphobic. b. has a history of intimate partner violence. C. demonstrates bizarre somatic delusions. D. verbalizes hopelessness and powerlessness.

b. has a history of intimate partner violence. A history of prior aggression or violence is the best predictor of patients who may become violent. Patients diagnosed with anxiety disorders are not particularly prone to violence unless panic occurs. Patients experiencing hopelessness and powerlessness may have co-existing anger, but violence is not often demonstrated. Patients experiencing paranoid delusions are at greater risk for violence than those with bizarre somatic delusions.

A victim of physical abuse by an intimate partner is treated for a broken wrist. The patient has considered leaving but says, You stay together, no matter what happens. Which outcome should be met before the patient leaves the emergency department? The patient will: a. limit contact with the abuser by obtaining a restraining order. b. name two community resources that can be contacted. C. demonstrate insight into the abusive relationship. D. facilitate counseling for the abuser.

b. name two community resources that can be contacted. The only outcome indicator clearly attainable within this time is for a staff member to provide the victim with information about community resources that can be contacted. The development of insight into the abusive relationship requires time. Securing a restraining order can be quickly accomplished but not while the patient is in the emergency department. Facilitating the abusers counseling may require weeks or months.

The nurse is caring for a client who had undergone a Whipple procedure 2 days previously. The nurse notes that the client's hands and feet are edematous, and urine output has decreased from the previous day. Which intervention does the nurse expect to provide for the client? a. Increase the clients IV fluid infusion rate. b. Monitor the client's blood sugar level every 4 hours. c. Add colloids to the clients IV solutions. d. Reinsert the clients nasogastric (NG) tube.

c. Add colloids to the clients IV solutions. Edema and low urine output following the Whipple procedure most likely are caused by hypoalbuminemia. Low albumin leads to third spacing of fluids and decreased intravascular fluids. As a result, edema and low urine output develop. Adding a colloid solution to the clients IV regimen will help shift edematous fluid from the interstitial space back into the intravascular space. Increasing the clients IV infusion rate will worsen the edema unless additional protein is added. Blood glucose monitoring and NG tubes are not related to this problem.

Chromosome analysis of the fetus is usually accomplished through the testing of which? a. Fetal serum b. Maternal urine c. Amniotic fluid d. Maternal serum

c. Amniotic fluid Amniocentesis is the most common method to retrieve fetal cells for chromosome analysis. Viable fetal cells are sloughed off into the amniotic fluid, and when a sample is taken, they can be cultured and analyzed. It is difficult to obtain a sample of the fetal blood. It is a high-risk situation for the fetus. Fetal cells are not present in the maternal urine or blood.

During a follow-up visit, a woman is describing new onset of marital discord with her terminally ill spouse. Using the Kubler-Ross behavioral theory, the nurse recognizes that the spouse is in which stage of dying? a. Denial b. Bargaining c. Anger d. Depression

c. Anger Kbler-Ross traditional theory involves five stages of dying. The anger stage of adjustment to an impending death can involve resistance, anger at God, anger at people, and anger at the situation. Denial would involve failure to accept death. Bargaining is an action to delay acceptance of death by bartering. Depression would present as withdrawal from others.

The nurse is counseling women at a crisis shelter about risk factors for increased intimate partner violence. What event is most likely to trigger an increase in abusive behaviors? a. Moving to a new community b. Starting a new job c. Becoming pregnant d. The death of a grandfather

c. Becoming pregnant Abuse is not likely to decrease, and can often increase when a woman becomes pregnant. Moving, starting a new job, and a death in the family are all stressors, but they are not identified as factors that specifically increase violence more than pregnancy.

Early diagnosis of congenital hypothyroidism (CH) and phenylketonuria (PKU) is essential to prevent which? a. Obesity b. Diabetes c. Cognitive impairment d. Respiratory distress

c. Cognitive impairment Untreated, both PKU and CH cause cognitive impairment. With newborn screening and early intervention, cognitive impairment from these two disorders can be prevented. Obesity, diabetes, and respiratory distress do not result from both CH and PKU.

The nurse working at a women's health clinic is seeing a teenage female patient who has come in for a refill on her birth control medication and with a complaint of abdominal pain. When the nurse enters the room, the patient is sitting in a chair with her head down, rocking back and forth, does not make eye contact, and answers questions with no expression on her face. What assessment question would be important for the nurse to ask the patient? a. What brings you to the clinic today? b. What can we do to help you today? c. Do you feel safe in your current relationship? d. Have you changed your diet lately?

c. Do you feel safe in your current relationship? This patient is exhibiting signs of being abused. It is important to ask about the safety of the patient. General questions about her visit do not give an opportunity for the patient to discuss her safety needs. While a diet change can cause stomach problems, this assessment would be addressed once safety is addressed.

Parents ask the nurse about the characteristics of autosomal dominant inheritance. Which statement is characteristic of autosomal dominant inheritance? a. Females are affected with greater frequency than males. b. Unaffected children of affected individuals will have affected children. c. Each child of a heterozygous affected parent has a 50% chance of being affected. d. Any child of two unaffected heterozygous parents has a 25% chance of being affected.

c. Each child of a heterozygous affected parent has a 50% chance of being affected. In autosomal dominant inheritance, only one copy of the mutant gene is necessary to cause the disorder. When a parent is affected, there is a 50% chance that the chromosome with the gene for the disorder will be contributed to each pregnancy. Males and females are equally affected. The disorder does not skip a generation. If the child is not affected, then most likely he or she is not a carrier of the gene for the disorder. In autosomal recessive inheritance, any child of two unaffected heterozygous parents has a 25% chance of being affected.

A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant. After taking the new medication, the patient states, This medication isn't working. I don't feel any different. What is the best response by the nurse? a. I will call your care provider. Perhaps you need a different medication. b. Don't worry. You can try taking it at a different time of day to help it work better. c. It usually takes a few weeks for you to notice improvement from this medication. d. Your life is much better now. You will feel better soon.

c. It usually takes a few weeks for you to notice improvement from this medication Seeing a response to antidepressants takes 3 to 6 weeks. No change in medications is indicated at this point of treatment because there is no report of adverse effects from the medication. If nausea is present, taking the medication with food may help, but this is not reported by the patient, so a change in administration time is not needed. Telling a depressed patient that their life is better does not acknowledge their feelings.

Which is a sex chromosome abnormality that is caused by the presence of one or more additional X chromosomes in a male? a. Turner b. Triple X c. Klinefelter d. Trisomy 13

c. Klinefelter Klinefelter syndrome is characterized by one or more additional X chromosomes. These individuals are tall with male secondary sexual characteristics that may be deficient, and they may be learning disabled. An absence of an X chromosome results in Turner syndrome. Triple X and trisomy 13 are not abnormalities that involve one or more additional X chromosomes in a male (Klinefelter syndrome).

A father with an X-linked recessive disorder asks the nurse what the probability is that his sons will have the disorder. Which response should the nurse make? a. Male children will be carriers. b. All male children will be affected. c. None of the sons will have the disorder. d. It cannot be determined without more data.

c. None of the sons will have the disorder. When a male has an X-linked recessive disorder, he has one copy of the allele on his X chromosome. The father passes his Y chromosome (not the X chromosome) to his sons. Therefore, none of his sons will have the X-linked recessive gene. They will not be carriers or be affected by the disorder. No additional data are needed to answer this question.

The nurse is teaching the family of a child, age 8 years, with moderate hemophilia about home care. What should the nurse tell the family to do to minimize joint injury? a. Administer nonsteroidal anti-inflammatory drugs (NSAIDs). b. Administer DDAVP (synthetic vasopressin). c. Provide intravenous (IV) infusion of factor VIII concentrates. d. Encourage elevation and application of ice to the involved joint.

c. Provide intravenous (IV) infusion of factor VIII concentrates. Parents are taught home infusion of factor VIII concentrate. For moderate and severe hemophilia, prompt IV administration is essential to prevent joint injury. NSAIDs are effective for pain relief. They must be given with caution because they inhibit platelet aggregation. A factor VIII level of 30% is necessary to stop bleeding. DDAVP can raise the factor VIII level fourfold. Moderate hemophilia is defined by a factor VIII activity of 4.9. A fourfold increase would not meet the 30% level. Ice and elevation are important adjunctive therapy, but factor VIII is necessary.

A couple is informed that their fetus condition is incompatible with life after birth. Nurses can best help the couple with their end-of-life decision making by offering them which of the following? a. An advance directive to complete b. Brief discussion and funeral guidance c. Time and careful explanations d. Instructions on how to proceed

c. Time and careful explanations Families can have limited knowledge when asked to make important ethical decisions. Nurses have the time, patience, and knowledge base to assist the family to understand their ethical situation and to help them make their own educated decision. Advance directives are completed by the person who is dying. Funeral guidance is best provided by a chaplain or a caretaker.

An individual who is a carrier is asymptomatic but possesses a genetic alteration, either in the form of a gene or chromosome change. Alleles are alternative expressions of genes at a different locus. A pedigree is a diagram that describes family relationships, gender, disease, status, or other relevant information about a family. Multifactorial describes a complex interaction of both genetic and environmental factors that produce an effect on the individual. Which genetic term refers to the transfer of all or part of a chromosome to a different chromosome after chromosome breakage? a. Trisomy b. Monosomy c. Translocation d. Nondisjunction

c. Translocation Translocation is the transfer of all or part of a chromosome to a different chromosome after chromosome breakage. It can be balanced, producing no phenotypic effects, or unbalanced, producing severe or lethal effects. Trisomy is an abnormal number of chromosomes caused by the presence of an extra chromosome, which is added to a given chromosome pair and results in a total of 47 chromosomes per cell. Monosomy is an abnormal number of chromosomes whereby the chromosome is represented by a single copy in a somatic cell. Nondisjunction is the failure of homologous chromosomes or chromatids to separate during mitosis or meiosis.

Which safety measure is most important for the nurse to institute for a client who has Cushings disease? a. Pad the side rails of the client's bed. b. Assist the client to change positions slowly. c. Use a lift sheet to change the clients position. d. Keep suctioning equipment at the client's bedside.

c. Use a lift sheet to change the clients position. Cushing's syndrome or disease greatly increases the serum levels of cortisol, which contributes to excessive bone demineralization and increases the risk for pathologic bone fracture. The client should not require suctioning. Padding the side rails and assisting the client to change position may be effective, but these measures will not protect him or her as much as using a lift sheet.

An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, My parents dont like me. They call me stupid and say I never do anything right. Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic

c. Emotional Examples of emotional abuse include having an adult demean a child's worth or frequently criticize or belittle a child. No data support physical battering or endangerment, sexual abuse, or economic abuse.

A nurse cares for a client with acute pancreatitis. The client states, I am hungry. How should the nurse reply? a. Is your stomach rumbling or do you have bowel sounds? b. I need to check your gag reflex before you can eat. c. Have you passed any flatus or moved your bowels? d. You will not be able to eat until the pain subsides.

c. Have you passed any flatus or moved your bowels? Paralytic ileus is a common complication of acute pancreatitis. The client should not eat until this has resolved. Bowel sounds and decreased pain are not reliable indicators of peristalsis. Instead, the nurse should assess for passage of flatus or bowel movement.

After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. The capsules can be opened and the powder sprinkled on applesauce if needed. b. I will wipe my lips carefully after I drink the enzyme preparation. c. The best time to take the enzymes is immediately after having a meal or a snack. d. I will not mix the enzyme powder with food or liquids that contain protein.

c. The best time to take the enzymes is immediately after having a meal or a snack. The enzymes should be taken immediately before eating meals or snacks. If the client cannot swallow the capsules whole, they can be opened up and the powder sprinkled on applesauce, mashed fruit, or rice cereal. The client should wipe his or her lips carefully after drinking the enzyme preparation because the liquid could damage the skin. Protein items will be dissolved by the enzymes if they are mixed together.

Which referral is most appropriate for a woman who is severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. Support group b. Law enforcement c. Women's shelter d. Vocational counseling

c. Women's shelter Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary.

A cognitively impaired patient has been a widow for 30 years. This patient is frantically trying to leave the unit, saying, I have to go home to cook dinner before my husband arrives home from work. To intervene with validation therapy, the nurse should first say: a. You must come away from the door. b. You have been a widow for many years. c. You want to go home to prepare your husbands dinner? d. Was your husband angry if you did not have dinner ready on time?

c. You want to go home to prepare your husbands dinner? Validation therapy meets the patient where she or he is at the moment and acknowledges the patients wishes. Validation does not seek to redirect, reorient, or probe. The incorrect options do not validate the patients feelings.

The nurse is caring for a client with acute pancreatitis. During the physical assessment, the nurse notes a grayish-blue discoloration of the clients flanks. Which is the nurse's priority action? a. Prepare the client for emergency surgery. b. Place the client in high Fowler's position. c. Insert a nasogastric (NG) tube to low intermittent suction. d. Ensure that the client has a patent large-bore IV site.

d. Ensure that the client has a patent large-bore IV site. Grayish-blue discoloration on the flanks (Turner's sign) indicates pancreatic enzyme leakage into the peritoneal cavity. This presents a risk of shock for the client, so IV access should be maintained with at least one large-bore patent IV catheter. The client may or may not need surgery; usually a fetal position helps with pain, and having an NG tube would not take priority over IV access.

Parents of a child with hemophilia A asks the nurse, What is the deficiency with this disorder? Which correct response should the nurse make? a. Hemophilia A has a deficiency in red blood cells. b. Hemophilia A has a deficiency in platelets. c. Hemophilia A has a deficiency in factor IX. d. Hemophilia A has a deficiency in factor VIII.

d. Hemophilia A has a deficiency in factor VIII. Hemophilia A is deficient in factor VIII. Glucose-6-phosphate dehydrogenase (G6PD) deficiency shows low red blood cells (hemolytic anemia). Immunosuppression may be the cause of a deficient number of platelets. Hemophilia B is deficient in factor IX.

What is probably the most important criterion on which to base the decision to report suspected child abuse? a. Inappropriate response of child b. Inappropriate parental concern for the degree of injury c. Absence of parents for questioning about child's injuries d. Incompatibility between the history and injury observed

d. Incompatibility between the history and injury observed Conflicting stories about the accident are the most indicative red flags of abuse. The child or caregiver may have an inappropriate response, but this is subjective. Parents should be questioned at some point during the investigation.

A couple asks the nurse about the optimal time for genetic counseling. They do not plan to have children for several years. When should the nurse recommend they begin genetic counseling? a. As soon as the woman suspects that she may be pregnant b. Whenever they are ready to start their family c. Now, if one of them has a family history of congenital heart disease d. Now, if they are members of a population at risk for certain diseases

d. Now, if they are members of a population at risk for certain diseases Persons who seek genetic evaluation and counseling must first be aware if there is a genetic or potential problem in their families. Genetic testing should be done now if the couple is part of a population at risk. It is not feasible at this time to test for all genetic diseases. The optimal time for genetic counseling is before pregnancy occurs. During the pregnancy, genetic counseling may be indicated if a genetic disorder is suspected. Congenital heart disease is not a single-gene disorder.

A child with hemophilia A will have which abnormal laboratory result? a. PT (ProTime) b. Platelet count c. Fibrinogen level d. PTT (partial thromboplastin time)

d. PTT (partial thromboplastin time) The basic defect of hemophilia A is a deficiency of factor VIII. The partial thromboplastin time measures abnormalities in the intrinsic pathway (abnormalities in factors I, II, V, VIII, IX, X, XII, HMK, and KAL). The prothrombin time measures abnormalities of the extrinsic pathway (abnormalities in factors I, II, V, VII, and X). Fibrinogen level is not dependent on the intrinsic pathway. Platelets are not affected with hemophilia A.

The nurse is caring for a child with hemophilia A. The child's activity is as tolerated. What activity is contraindicated for this child? a. Ambulating to the cafeteria b. Active range of motion c. Ambulating to the playroom d. Passive range of motion exercises

d. Passive range of motion exercises Passive range of motion exercises should never be part of an exercise regimen after an acute episode because the joint capsule could easily be stretched and bleeding could recur. Active range of motion exercises are best so that the patient can gauge his or her own pain tolerance. The child can ambulate to the playroom or the cafeteria.

When only one child is abused in a family, the abuse is usually a result of what? a. The child is the firstborn. b. The child is the same gender as the abusing parent. c. The parent abuses the child to avoid showing favoritism. d. The parent is unable to deal with the child's behavioral style.

d. The parent is unable to deal with the child's behavioral style. The child unintentionally contributes to the abuse. The fit or compatibility between the child's temperament and the parents ability to deal with that behavior style is an important predictor. Birth order and gender can contribute to abuse, but there is not a specific birth order or gender

Which statement is the most appropriate for the nurse to make when caring for bereaved parents? a. This happened for the best. b. You have an angel in heaven. c. I know how you feel. d. What can I do for you?

d. What can I do for you? Acknowledging the loss and being open to listening is the best action that the nurse can do. No bereaved parents would find the statement This has happened for the best to be comforting in any way, and it may sound judgmental. Nurses must resist the impulse to speak about the afterlife to people in pain. They should also resist the temptation to give advice or to use cliches. Unless the nurse has lost a child, he or she does not understand how the parents feel.

What is the primary motivator for most rapists? a. Anxiety b. Need for humiliation c. Overwhelming sexual desires d. Desire to humiliate or control others

d. Desire to humiliate or control others Rape is not a crime of sex; rather, it is a crime of power, control, and humiliation. The perpetrator wishes to subjugate the victim. The dynamics listed in the other options are not the major motivating factors for rape.

The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patients discharge? a. Patient states, I feel safe and entirely relaxed. b. Memory of the rape is less vivid and frightening. c. Physical symptoms of pain and discomfort are no longer present. d. Patient agrees to keep a follow-up appointment with the rape crisis center.

d. Patient agrees to keep a follow-up appointment with the rape crisis center. Agreeing to keep a follow-up appointment is a realistic short-term outcome. The incorrect options are unlikely to occur during the limited time the victim is in the emergency department.

An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurses priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries

d. Physical injuries The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options.

A patient is hospitalized after an arrest for breaking windows in the home of a former domestic partner. The history reveals childhood abuse by a punitive parent, torturing family pets and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury b. Post-trauma response c. Disturbed thought processes d. Risk for other-directed violence

d. Risk for other-directed violence The defining characteristics for Risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. The defining characteristics for the other diagnoses are not present in this scenario.

A rape victim asks an emergency department nurse, Maybe I did something to cause this attack. Was it my fault? Which response by the nurse is the most therapeutic? a. Pose questions about the rape, helping the patient explore why it happened. b. Reassure the victim that the outcome of the situation will be positive. c. Make decisions for the victim because of the temporary confusion. d. Support the victim to separate issues of vulnerability from blame.

d. Support the victim to separate issues of vulnerability from blame. Although the victim may have made choices that increased vulnerability, the victim is not to blame for the rape. The incorrect options either suggest the use of a nontherapeutic communication technique or do not permit the victim to restore control. No confusion is evident.