PCC 1- Exam 1: Diversity, Family Dynamics, IPV, and Sexuality

The nurse explains to a 24-year-old pregnant client with a sexually transmitted disease (STD) that follow-up care includes: A. contacting and treating all sexual partners. B. amniocentesis for evaluation of genetic damage. D. close monitoring of hemoglobin and hematocrit. D. delivery by cesarean section.

Answer: A Rationale: All partners have been exposed and should be made aware, tested, and treated as indicated. A cesarean is needed only if herpes lesions are present or there are prodromal symptoms at delivery. Genetic evaluation and more frequent monitoring of hemoglobin and hematocrit are not indicated.

The nurse is talking with a 15-year-old client experiencing dysmenorrhea who asks if there are any remedies for the pain. The nurse responds with which advice? A. "The recommended medication is an NSAID." B. "Increase the intake of sodium." C. "Antibiotics will help the symptoms to subside." D. "Pain lasts only a few days and does not need treatment."

Answer: A Rationale: An NSAID is effective for pain and the reduction of inflammation that may be causing pain. The client is helped to be free of pain, not to endure it. Antibiotics are not effective against pain and increasing sodium intake will increase edema and possibly the discomfort.

A 63-year-old client with Alzheimer disease is brought to the emergency department (ED) with pressure sores and severe dehydration. Upon further assessment, the nurse notices bruises on the client's neck, arms, and legs. Which question could the nurse ask the client's spouse? A. "What kind of support do you have at home to care for your spouse?" B. "Have you considered placing your spouse in a nursing home?" C. "How often do you turn your spouse while your spouse is in bed?" D. "How long do you leave your spouse at home alone?"

Answer: A Rationale: Asking about support at home will assess the support system and ability of the spouse to care for the client in a safe manner. This question also indicates that the nurse is aware of possible stress on the caregiver without accusing the spouse of abuse. Asking about placing the client in a nursing home subtly implies the spouse is abusing the client and is unable to care for the client properly. The nurse first assesses the client before planning interventions. Asking about turning the client in bed does not assess the possibility of caregiver strain nor does it offer support to the caregiver. Asking about the length of time the client is alone assumes that the client's injuries are signs of neglect or abuse.

A 22-year-old client is diagnosed with pelvic inflammatory disease (PID) after a pelvic examination. After the exam, the client touches her breast and offers the nurse oral sex. What is the appropriate response by the nurse? A. "Your behavior is inappropriate and embarrassing. Sometimes individuals talk like that when they are concerned about their illness and sexual life. Would you like to talk about your fears?" B. "Stop or I'm calling the authorities." C. "Why are you doing this? Please stop; this is embarrassing." D. "What did the doctor say? Can you still have sex?"

Answer: A Rationale: Before implementing any nursing interventions, the nurse should first determine whether the behavior is inappropriate or an attempt to communicate a physical need. Communicate that the behavior is not acceptable; Tell the client how the behavior makes you feel; Identify the behavior you expect; Set firm limits; Try to refocus clients from the inappropriate behavior to their real concerns and fears; offer to discuss sexuality concerns; Report the incident to your nursing instructor, charge nurse, or clinical nurse specialist. Discuss the incident, your feelings, and possible interventions; Assign a nurse who will confront the behavior and relate to the client in a consistent manner; and clarify the consequences of continued inappropriate behavior.

The nurse is working with a client from a different culture who thinks his illness is due to his past sins. The nurse's best response to the client is: A. "Can you tell me more about what you are thinking?" B. "I think you are being very hard on yourself." C. "You seem like such a nice person." D. "You have an infection that is caused by a virus.

Answer: A Rationale: By inviting the client to say more, the nurse may gain more insight and information before deciding on a course of action. The other statements negate the client's feelings and are not therapeutic.

When discussing dietary guidelines with a woman who has premenstrual syndrome (PMS), the nurse recommends that the client reduce sodium intake for which reason? A. Sodium restriction helps minimize fluid retention. B. In and of itself, sodium is not harmful, but it may reduce cancer risks. C. Sodium increases reactive hypoglycemia, increasing physical manifestations. D. Sodium increases thirst, thereby facilitating increased oral fluid intake.

Answer: A Rationale: For a woman with PMS, the nurse would recommend a decrease in sodium intake to help minimize the fluid retention due to increased production of aldosterone, which results in sodium retention and edema. Sodium does not increase reactive hypoglycemia and does not reduce cancer risks. Sodium does increase thirst but is not the reason for restriction in this case

A nurse working in a primary care clinic is caring for a client whose is grieving due to the recent death of her spouse. Appropriate nursing interventions for this client include all except: A. Suggest the use of anti-anxiety medications to aide in coping. B. Teach about healthy coping strategies. C. Facilitate referrals to grief counselors and other professional resources. D. Provide information about therapy and support groups.

Answer: A Rationale: Grief is evidenced by sadness, anger, denial, and pain associated with the loss. Appropriate nursing interventions for a grieving client include providing information about therapy and support groups, teaching about healthy coping strategies, and facilitating referrals to grief counselors. Suggesting the use of anti-anxiety medications to aide in the coping is not a healthy coping strategy and is an inappropriate intervention.

A nurse caring for a client who has begun menopause selects the nursing diagnosis of deficient knowledge when the client makes which statement? A. "I must be coming down with the flu because I am having hot flashes." B. "I should increase my daily calcium intake to 1200 mg." C. "I need to begin weight-bearing exercises such as walking." D. "I need to obtain yearly mammograms."

Answer: A Rationale: Hot flashes are a sign of menopause, not the flu. The nurse provides the client with education about symptoms and lifestyle changes for the woman entering menopause. Increasing calcium intake, weight-bearing exercises, and yearly mammograms are all recommendations for the perimenopausal woman.

The nurse is caring for a client involved in a motor vehicle crash that sustained an intracranial hemorrhage. The client's condition is deteriorating and the nurse notes that the client's intracranial pressure is rising to dangerous levels. This assessment finding would indicate that the physician is considering which treatment? A. Surgery B. Physical therapy C. A blood thinner D. Occupational therapy

Answer: A Rationale: Intracranial pressure (ICP) will be monitored when a head injury is present, and if the pressure rises to dangerous levels, surgery will be performed to release some of the pressure. The client has an intracranial hemorrhage, therefore, administering a blood thinner would be contraindicated. While therapy and occupational therapy may be required for this client, it is not of immediate concern based on the findings.

Which factor, if reported to the nurse by a client prior to collection of a gonorrhea culture, would result in postponing the specimen collection? A. Currently menstruating B. Persistent vaginal discharge C. Douching 3 days ago D. Recent diagnosis and treatment for vaginal herpes

Answer: A Rationale: Menstrual blood can affect the results of a gonorrhea culture. Douching within 24 hours may affect results. Persistent discharge and recent diagnosis of herpes are not barriers to specimen collection.

A nurse concerned with family wellness promotion understands that The National Wellness Institute (NWI) has proposed six dimensions of wellness including all except: A. Moral B. Occupational C. Physical D. Social

Answer: A Rationale: NWI proposed six dimensions of wellness: occupational, physical, social, intellectual, spiritual, and emotional wellness. These dimensions are all interconnected, contributing to an individual's overall well-being. Morality is not one of the proposed six dimensions of wellness.

An older client, brought to an agency by an adult child, is demonstrating signs and symptoms of fluid retention related to excessive sodium intake. Further nursing assessment indicates inadequate food storage and preparation techniques in the home. Which of the following nursing diagnoses is the most appropriate for this family? A. Readiness for Enhanced Family Coping B. Impaired Parenting C. Disabled Family Coping D. Caregiver Role Strain

Answer: A Rationale: Presenting to the clinic indicates the family is probably ready to face the health challenges caused by previous activities. There is no evidence that the adult child or parent is experiencing disabling coping. Impaired parenting applies when the parent is unable to care for the child rather than the reverse. Although some strain may be experienced by the caregiver, there is no evidence that role strain is the most important aspect of this situation.

The nurse is explaining to a client with erectile dysfunction (ED) about nocturnal penile tumescence and rigidity (NPTR) monitoring. The nurse knows that which test will help determine if the client's ED is psychogenic or organic in nature? A. At a sleep study lab B. At the hospital C. In his own home D. At the clinic

Answer: A Rationale: The NPTR test is conducted in a sleep study lab, as the number and quality of erections during REM sleep are what is being measured. The home, hospital, or clinic is not equipped for sleep studies.

The nurse is assessing a 37-year-old woman who is complaining of mood swings, breast tenderness, and food cravings. The nurse asks the client for which additional information? A. "When and how often do these symptoms appear?" B. "Have you been in an accident?" C. "Do you have a chronic disease?" D. "Do you have edema as well?"

Answer: A Rationale: The client is exhibiting symptoms of premenstrual syndrome (PMS), and the nurse would ask the client when and how often the symptoms occur in an effort to determine if the menses is the problem. These symptoms are not those of a person experiencing trauma or a chronic disease. The client may well have edema, but asking that elicits only more symptoms; the goal is to associate the symptoms with the menstrual cycle to diagnose PMS.

There are several factors that can be considered direct or indirect causes of rape. Which comment made by the student nurse indicates the need for further instruction? A. "There are only sociocultural factors when considering the cause of rape." B. "A psychological disorder that causes impaired decision making is an example of a biological factor." C. "Growing up in a setting where physical, emotional, or sexual violence were common is an example of an environmental factor." D. "Two of the most common forms of rape are marital rape and date rape."

Answer: A Rationale: The statement, "There are only sociocultural factors when considering the cause of rape," is an inaccurate statement because there can be intrapersonal and interpersonal factors, as well as sociocultural factors. Some of the factors considered sociocultural factors are biological and environmental. Biological factors would include psychological disorders that cause impaired decision making, or deficient impulse control. Environmental factors which could influence an individual's decision to commit rape could include growing up in a setting where physical, emotional, or sexual violence were common, and perhaps even accepted. There are various forms of rape. Two of the most common forms of rape are marital rape and date rape. KEY WORD= ONLY

A high school freshman has been teased and taunted about his small size by senior class members. He has no close friends and usually sits alone when eating lunch in the cafeteria. When he fell down in physical education class, the other students laughed and called him "klutz." The school nurse should provide further teaching if the nursing student selected which nursing diagnosis for this teen? A. Risk for other-directed violence related to history of violent behaviors B. Fear related to being taunted and humiliated by peers C. Loneliness related to rejection from peers and feelings of isolation D. Self-esteem disturbance related to being teased about small size

Answer: A Rationale: There are no data to support the nursing diagnosis of risk for other-directed violence related to history of violent behaviors. The student has not made any violent threats, exhibited signs of uncontrolled anger, or brandished a firearm. Loneliness related to rejection from peers and feelings of isolation is an appropriate nursing diagnosis because he lacks a sense of belonging as evidenced by his isolative behaviors. Self-esteem disturbance related to being teased about small size is an appropriate nursing diagnosis because his small frame and freshman status make him vulnerable to low self-esteem issues. Fear related to being taunted and humiliated by peers is an appropriate nursing diagnosis because his behavior indicates an inability to protect himself from bullying behavior.

What should the nurse do prior to beginning the assessment of a foreign-born, non-English-speaking client? A. Locate an interpreter for the assessment, preferably of the same sex as the client. B. Find out if a family member is available to interpret for the nurse and client. C. Create a checklist of assessment questions, using the easiest medical jargon to limit words. D. Prepare the assessment questions in advance so the interpreter can read them to the client.

Answer: A Rationale: When using an interpreter for client care, the nurse should use an interpreter of the same sex as the client. To protect client confidentiality, family members should not be asked to interpret for the nurse or client. The nurse should talk to the client, even in the presence of an interpreter. The nurse should not prepare questions in advance and expect the interpreter to read them to the client. The nurse should limit the use of medical jargon, so creating a checklist of assessment questions using medical jargon to limit words would be inappropriate.

The nurse is conducting a support group for those clients who have been in an abusive relationship. Which is an accurate description of abuse? A. A pattern of behavior that takes away freedom of choice B. The taking of one's own life C. Injury incurred from an act of violence D. A fatal injury incurred from an act of violence

Answer: A Rationale: Abuse is described as a pattern of behavior that dominates, controls, lowers self-esteem, or takes away freedom of choice. Can include elder abuse, child abuse, intimate partner abuse, and sexual abuse. Suicide is the taking of one's own life. Assault is described as injury from an act of violence where physical force is used with intent to harm and homicide is injury from an act of violence where physical force is used to kill.

The school nurse teaches elementary school teachers about occurrences of violence towards children. The nurse knows that further teaching is necessary if a teacher makes which statement? A. "Children with special needs are less vulnerable to physical abuse than other children." B. "Physically abused children may appear overly submissive and eager to please their teacher." C. "Children who are physically abused by their parents are more likely to abuse siblings." D. "Poor hygiene and inappropriate clothing are possible signs of child abuse."

Answer: A Rationale: Caregiver stress and frustration may lead to abuse or even homicide of children with special needs. Children who are physically abused by their parents are more likely to abuse siblings; sibling abuse is the most unrecognized form of abuse. Physically abused children may appear overly submissive and eager to please their teacher; abused children are frequently overly compliant in response to all adults. Inadequate physical care or lack of care for a child may be a sign of child abuse.

The nurse observes the client from another country becomes restless and avoids eye contact when the nurse discusses birth control. What should the nurse do to demonstrate cultural competence? A. Ask the client if this is something that she would like to learn. B. Close the room door and provide the client with something to drink. C. Ask the client if there is a family member that should be present. D. Tell the client that the instruction can occur later when she is feeling better.

Answer: A Rationale: Cultural competence is the ability to apply the knowledge and skills needed to provide quality care to clients of different cultures. The nurse is instructing a client from a different culture regarding birth control. It is not clear whether the nurse assessed this client's desire to learn about birth control, and the client's nonverbal behavior could serve as a clue. The nurse should ask the client if this is something that she would like to learn. Closing the door and providing the client with something to drink will not address the client's nonverbal behavior. Asking the client if there is a family member who should be present does not address whether the client wants to participate in the instruction. Telling the client that the instruction can occur later when she is feeling better is assuming that the client is not feeling well and not addressing the client's nonverbal behavior.

A female was sexually assaulted in the parking lot of a mall and was brought to the emergency department by a friend. Which is considered improper procedure when conducting a sexual assault assessment? A. The victim uses the bathroom and washes her hands before the examination begins. B. The nurse documents the victim's verbal and nonverbal behavior. C. At the victim's request, the friend is present during the examination. D. After obtaining permission, the nurse takes photographs of the victim's injuries.

Answer: A Rationale: It is improper procedure for the victim to use the bathroom and wash her hands before the examination begins because valuable forensic evidence may be destroyed. The victim has the right to have friends or family present during the assessment. The victim must give permission before any photographs or other evidence is collected. Careful documentation of the victim's statements and behavior must be done to assist with possible prosecution of the perpetrator.

The nurse is preparing to educate a group of adolescents on violence and violence prevention. The nurse is aware that violence results from a combination of factors. Which are considered protective factors? A. Involvement in the community B. Continually being bullied by a student at school C. A childhood history of abuse D. Living in an impoverished community

Answer: A Rationale: Protective factors decrease the risk of violence perpetration and victimization; therefore involvement in the community is considered a factor that would reduce the risk associated with violence. Living in an impoverished community is considered a predisposing factor. A childhood history of abuse is an influential factor and continually being bullied by a student at school is a precipitating factor.

Which collaborative treatment option would be most appropriate for each of these alterations in violence, including abuse, assault, rape, and suicide? A. Support groups B. Pharmacological therapy C. Sexually transmitted disease testing D. Legal interventions

Answer: A Rationale: Support groups would be an appropriate therapy for all alterations in violence mentioned above. Sexually transmitted disease testing would be appropriate for rape. Based on the information provided pharmacological therapy would primarily be appropriate for suicide and rape. Legal intervention would be for abuse, assault, and rape.

Which finding indicates a positive outcome in the treatment of a client who suffered trauma injuries from a motor vehicle crash? A. An oxygen saturation of 96% on 2L NC B. A respiratory rate of 36 C. A pulse rate of 140 D. An oxygen saturation of 90% on room air

Answer: A Rationale: An oxygen saturation of 96% on 2L NC would be a desired outcome for a client. A positive outcome for a client would be maintaining an oxygen saturation of greater than 95%; therefore an oxygen saturation of 90% on room air would not be a desired outcome. It is also desired that the respiratory rate and pulse rate maintain within normal limits. The pulse rate of 140 and respiratory rate of 36 are not within normal limits.

A client who is paralyzed from severe injuries sustained during an automobile accident continually attempts to perform activities beyond capabilities. Which is the most appropriate nursing diagnosis for this client? A. Ineffective denial B. Risk for trauma C. Anxiety D. Disturbed image

Answer: A Rationale: The client is exhibiting signs of denial by failure to adjust to the limitations of paralysis. The client may have anxiety and a disturbed body image, but the priority here is the denial. The client is not at risk for trauma since that has already happened.

When the spouse of an older person dies, which tasks need to be accomplished? (Select all that apply.) A. Adjusting to the aging client B. Planning for retirement C. Coping with lack of privacy D. Coping with loss E. Relating to kin

Answer: A and D Rationale: The surviving spouse needs to recognize that dying is a part of adjusting to aging and that bodily changes occur as a result of aging. Coping with loss is a part of grieving that the widow or widower must endure as a result of the death of the spouse. Although coping with lack of privacy may occur if the older adult moves in with family members, that is not what is being addressed here. Planning for retirement may be a part of what is happening, but it is not what is occurring in this setting. Relating to kin may also be occurring, but it is not pertinent to this situation.

The nurse is teaching older women about health risks for the postmenopausal period and would include which as health risks? (Select all that apply.) A. Macular degeneration B. Breast cancer C. Gout D. Joint degeneration E. Cognitive changes

Answer: A, B, and E Rationale: Due to hormonal changes, postmenopausal women have a greater risk for macular degeneration, breast cancer, and cognitive changes than do premenopausal women. Joint degeneration and gout are not associated with menopause.

The nurse is conducting a class for middle-aged males about risks for erectile dysfunction and includes which risks while teaching? (Select all that apply.) A. The client is morbidly obese. B. The client is more than 64 years old. C. The client has diabetes mellitus. D. The client takes propranolol. E. The client uses herbal supplements.

Answer: A, C, and D Rationale: Hypertension and hypertensive medications, diabetes, and morbid obesity are all risk factors for erectile dysfunction that have little to do with sexual desire. Age and herbal supplements are not necessarily related to erectile dysfunction.

Which essential factors does the nurse assess when determining the impact of a family member's serious illness on the family? (Select all that apply.) A. Duration of the illness B. The coping mechanisms used by other families with similar illnesses C. The meaning of the illness to the family D. The financial impact of the illness E. The incidence of the illness in the community at large

Answer: A, C, and D Rationale: It is essential that the nurse determines the duration of the illness, the meaning of the illness, and the financial impact of the illness in order to completely plan to meet the family's needs as well as those of the client. Coping mechanisms used by other families are not relevant at this stage, as the nurse does not yet know what the family's needs are. Knowing the incidence of the illness in the community is important for the community health nurse, but will not help the nurse plan care for this specific family.

The nurse is teaching a male client about the use of condoms to reduce the risk of sexually transmitted disease (STD). The nurse includes which topics for discussion? (Select all that apply.) A. Use a new condom with each sex act. B. Use oil-based lubricants such as petroleum jelly. C. Withdraw while the penis is erect. D. Allow space at the tip of the condom. E. Handle the condom carefully to ensure no damage

Answer: A, C, and E Rationale: Important client teaching for the male client learning to use a condom includes application of a new condom prior to each sex act as condoms should never be reused. Withdrawal of the penis while still erect and holding the base of the condom will prevent leakage of semen. The condom is made thin to allow for maximum sensation so it is easily torn or broken and must be handled carefully. The condom must be applied to allow air at the tip to provide space for the ejaculate to be collected. Oil-based lubricants should not be used as they can damage the condom and increase risk of condom failure. Water based lubricants may be used if needed.

The nurse is teaching coping skills to clients who have experienced sexual trauma. Which outcome demonstrates that the teaching has been successful? (Select all that apply.) A. The client talks of the past more than the present. B. The client enjoys an intimate relationship with a significant other. C. The client practices deep breathing techniques when intrusive memories occur. D. The client verbalizes feelings of anger and despair from past sexual abuse. E. The client restructures negative thoughts and makes positive self-statements.

Answer: All but A Rationale: The client who is able to enjoy an intimate relationship with a significant other is demonstrating the ability to relate to another; this is a barrier for those who have experienced sexual trauma. Verbalizing feelings of anger and despair from past sexual abuse allows the client explores these feelings before moving on to self-forgiveness and more complete healing. Practicing deep breathing techniques when intrusive memories occur is an effective stress management technique to self-soothe one's anxiety. Ability to restructure negative thoughts and make positive self-statements demonstrates a cognitive ability to monitor irrational thoughts and replace them with rational ones. Talking of the past more than the present indicates that the client is dwelling on past sexual abuse and is not able to move forward with life.

The nurse is preparing a violence prevention program for a group of adolescents. Which are warning signs of impending violence? (Select all that apply.) A. Disagreeing B. Uncontrolled anger C. Threatening language D. Aggression E. Inappropriate behavior

Answer: All but A Rationale: Individual violence prevention involves recognition of the warning signs of potentially violent behavior such as, uncontrolled anger, threatening language, and aggression. Assessing for inadequate coping mechanisms, signs of inadequate anger management, or inappropriate behavior can help to identify potentially violent tendencies and implement behavior therapy before someone is victimized. Disagreeing is not a warning sign of impending violence.

The nurse is caring for a 10-year old child who is a victim of physical and sexual abuse. Which assessment techniques should the nurse employ when assessing an abused child? (Select all that apply.) A. The nurse needs to assure the child that they believe them. B. Ensure the child's safety. C. The nurse needs to let the child know that the abuser is a very bad person. D. The nurse needs to make sure the admission process is not repetitive. E. Develop a trusting relationship.

Answer: All but C Rationale: The priority nursing consideration is to ensure the child's safety. It is also important to develop a trusting relationship, let the child know they believe them, and assure the admission process is not repetitive. It is inappropriate for the nurse to make negative comments about the abuser.

A 56-year-old client diagnosed with multiple sclerosis complains that she and her husband have not had sex since she stopped walking one year ago. She states, "We are still attracted to each other, but how can I have sex when I can't move my legs?" What is the priority nursing plan for this client? A. Provide education in safe sex practices. B. Educate the client about changes in position and other ways to share intimacy. C. Allow the client to communicate her anger and frustrations. D. Ask the client if her husband has problems with erectile dysfunction.

Answer: B Rationale: Alteration in mobility can affect sexual relations; however the nurse can educate clients with mobility alterations about changes in positions that may facilitate coitus and to discuss other ways to share intimacy.

The nurse is taking care of a 46-year-old client status post angioplasty, who complains that he is still "having problems in the bedroom." The client states, "I think I might have to have another procedure done." What is the nurse's priority response? A. "Have you discussed this with your wife?" B. "Are you taking Digoxin (Lanoxin)?" C. "I think you need to see a sex therapist." D. "Let's call the doctor in now."

Answer: B Rationale: Alteration in perfusion can cause erectile dysfunction due to arterial and/or venous flow. The client had an angioplasty to correct his perfusion issues; however, cardiotonics like digoxin, used to correct vascular supply, can cause decreased sexual desire, erectile dysfunction, and ejaculatory failure.

The nurse who views a family holistically understands all families have certain structural and functional features in common. These include all except: A. Interdependence B. Breaking boundaries C. Adapting to change D. Performing family tasks

Answer: B Rationale: Although each family is unique, all families have certain structural and functional features in common. These include: Interdependence, adapting to change, performing family tasks, and maintaining boundaries.

The nurse is instructing a 68-year-old client with a history of MI and erectile dysfunction about adverse effects of taking tadalafil (Cialis). The nurse instructs the client to notify the physician if he experiences: A. one erection in 36 hours. B. an erection lasting more than 4 hours. C. sleeping for 9 hours. D. disinterest in sexual activity.

Answer: B Rationale: An erection that last more than 4 hours is an adverse effect and needs immediate attention to prevent damage to the penis. One erection in 36 hours is an expected effect. Disinterest in sex and sleeping for 9 hours are not effects of the medication.

A client comes to the emergency department with multiple bruises on the face and head. The nurse suspects that domestic violence may be the cause of the injuries. What is the most appropriate initial action for the nurse to take? A. Refer the client to a shelter for battered partners. B. Ask if the client is afraid of being hurt by someone at home. C. Document the concern, but do nothing else. D. Call a social worker to evaluate the client for domestic violence.

Answer: B Rationale: Asking if the client is being hurt is a critical step in a comprehensive assessment. Referring the client to a shelter without assessment may be a disservice; the nursing process requires assessment before intervention. After assessment and the determination of domestic violence, collaboration with social services is appropriate. Documenting the assessment does nothing to help the client resolve the issue.

A nurse is planning care for a client who is terminally ill. The client's spouse still works fulltime in order to pay for medical bills. The nurse determines the priority nursing diagnoses appropriate for the family is: A. Impaired home maintenance B. Caregiver role strain C. Disabled family coping D. Impaired parenting

Answer: B Rationale: Caregiver role strain is the most appropriate nursing diagnosis in this case. The client's spouse must continue to work while the client's health deteriorates. Impaired home maintenance and disabled family coping may occur due to the client's health, however, this is not the priority nursing diagnosis. Impaired parenting is not an appropriate nursing diagnosis for this instance.

The nurse is evaluating the efficacy of the family nursing care plan and identifies if the family members have achieved the outcomes relevant to each nursing diagnosis. These outcomes include all except the following: A. Family members demonstrate the ability to identify realistic personal and family goals. B. Family members express the burden of caregiving. C. Family members identify and demonstrate healthy coping strategies. D. Family members demonstrate support of the primary caregiver.

Answer: B Rationale: During evaluation, the nurse also examines all aspects of the nursing care plan to determine the effectiveness of nursing interventions, as well as to evaluate the continued relevance of original nursing diagnoses. Based on evaluation, the nursing care plan is modified to meet the family's current needs. The outcome relevant to evaluating the efficacy of the family nursing care plan include: family members demonstrate the ability to identify realistic personal and family goals; family members identify and demonstrate healthy coping strategies; and family members demonstrate support of the primary caregiver. Family members who express the burden of caregiving is maladaptive.

The nurse firsts performs which task prior to initiating interventions of a family-centered care plan? A. Meet with all family members simultaneously. B. Establish a trusting relationship with each family member. C. Confirm that the family health insurance covers all members. D. Complete a thorough history and assessment of each member of the family.

Answer: B Rationale: For the nurse to be able to promote family health and treat the family during illness, the nurse must establish a trusting relationship with the family to allow for effective communication and to confirm that goals are mutual. Even though confirming that the family's health insurance coverage covers all members is important, it is not the priority. A detailed history of each member is important, but the family needs to trust the nurse first for the histories to be valid. Meetings with the family as a group should be done after the relationship is established and the nurse can explore goals for the group.

A client has an obstruction between the uterus and the fallopian tube. In obtaining a health history, the nurse collects data about which of the following that may have caused the problem? A. Smoking 2 packs of cigarettes a day B. Pelvic inflammatory disease (PID) caused by gonorrhea C. Rubella infection prior to adolescence D. Ingestion of 2 ounces of alcohol per day

Answer: B Rationale: Infectious diseases of the reproductive tract, such as PID, can cause scarring and tubal blockage. Rubella infection during childhood results in immunity to the disease. Smoking and alcohol present health risks to the woman, but do not obstruct the fallopian tubes.

The nurse is teaching a group of clients about sexually transmitted infections (STI). The nurse knows that teaching is successful when the clients identify that the infective organism responsible for gonorrhea initially targets which body part? A. Female vulva and vagina B. Male urethra and female cervix C. Male prostate D. Male and female external genitalia

Answer: B Rationale: Initially, gonorrhea infects the male urethra and the female cervix. The vulva, vagina, prostate, and external genitalia are not initially infected by gonorrhea.

The nurse is working with clients to help them determine the best method of preventing pregnancy. Which client does the nurse determine is the best candidate for insertion of an intrauterine device? A. A client who is single, has no children, and who has multiple sexual partners. B. A client who is in a stable long-term relationship, has two children, and does not want to get pregnant for 3 years. C. A client who is unmarried, has no children, has had two miscarriages, and has a history of pelvic inflammatory disease.(PID) D. A client who is married, has one child, and wants to get pregnant in 6 months.

Answer: B Rationale: Intrauterine devices are recommended for women who have been pregnant, are in a monogamous relationship so that they are at low risk for sexually transmitted diseases, and who do not want a pregnancy for several years. A complication of intrauterine devices is PID, so the client who has a history of PID is not considered a good candidate for an ID.

A nursing instructor is supervising student interaction with clients. Which action taken by a student nurse would be of concern to the instructor and require the instructor to intervene? A. A student nurse asks a rape victim if she would like a friend or rape advocate present during the examination. B. A student nurse asks the rape victim to shower prior to the initial examination. C. A student nurse is providing support group information to a rape victim. D. A student nurse is providing resource information to a rape victim

Answer: B Rationale: It is not appropriate to have a rape victim shower prior to examination because a shower will remove potential evidence which could be collected and used to identify the attacker. When assessing a client's emotional needs, asking if they would like a parent, friend, or rape advocate present during the examination is appropriate. It is also appropriate to provide a rape victim with resources for therapy and support groups.

The nurse formulates a nursing diagnosis of ineffective family processes for the family of a child who has sustained a brain injury during an automobile accident. The nurse is aware that when considering this nursing diagnosis which intervention has the highest priority? A. Refer the family to supportive services in the community. B. Encourage the family to express feelings and ask questions. C. Explain the visiting rules of the intensive care unit. D. Teach the family the importance of using seat belts.

Answer: B Rationale: It is optimal to find out what the family's perception is of what is going on and what they feel their needs are. The best way to do this is to encourage them to ask questions and express their feelings. While families may need teaching about seat belts and sources of support, now is not the optimal time to institute these interventions. Most pediatric intensive care units have open visiting for the family.

A 27-year-old client has missed a menstrual cycle and comes to the clinic. The client states, "I know I'm pregnant, I'm never late." The nurse performs which priority test to determine pregnancy? A. A CBC with differential B. An HCG blood or urine test C. A serum hormone study D. A fasting hCG blood test

Answer: B Rationale: Laboratory tests for women related to the genitor reproductive system include laboratory tests for women include hCG (human chorionic gonadotropin) pregnancy tests (urine or blood) and Papanicolaou test (Pap test). Since the Pap test involves a pelvic examination, more teaching about the procedure and the test is required. The pregnancy tests and Pap test do not require that the woman be fasting.

The nurse concludes that a client has understood teaching about menopause when the client states the following: A. "I am depressed about having this disease." B. "I know I have begun menopause and it will take a while to finish." C. "I will experience symptoms of menopause for 2 weeks." D. "I have missed two periods now and am grateful I will have no more."

Answer: B Rationale: Menopause is a lengthy process since estrogen levels decrease gradually. The process may take years. Menopause is not a disease, but a normal physiological process. The client may miss several menstrual periods only to have one at a later time. Symptoms of menopause can last years, but do gradually decline with time.

The nurse is conducting a teaching session at a community center for women about rape. The nurse would conclude that which individual is at a higher risk for becoming a rape victim? A. A 30-year-old married female who works out of the home B. A 17-year-old high school student under the influence of alcohol C. An older client in a long-term care facility D. A 50-year-old woman living alone who rides a bus to work

Answer: B Rationale: No specific individual risk factors exist for becoming a victim of rape. Individuals can be at a higher risk for rape if they are under the influence of drugs and/or alcohol, but these factors do not cause rape to occur. Similarly, being young could be considered to be a risk factor for rape, but only due to the fact that a large percentage of victims report having been raped before they were 18 years old.

A 50-year-old client confides to the nurse that she is experiencing dyspareunia during sexual intercourse. The nurse recommends which therapy for this client? A. Consume alcohol to reduce inhibitions. B. Use a vaginal lubricant. C. Reduce sexual contact to once a month. D. Tell the partner that sex is no longer desired.

Answer: B Rationale: Older women and those experiencing menopause may have decreased vaginal secretions, causing a dry entry that can be painful and irritating to the vagina. The nurse could suggest using a lubricant to replace normal secretions. Before assessing for the problem, it is not appropriate to advise the client to tell the partner that sex is not desired. Advising the client to reduce sexual contact or use alcohol does not address the client's problem.

A client who has chosen to have a penile implant for erectile dysfunction is asking the nurse to explain the procedure to his spouse. What recommendation should the nurse make to help the couple adjust appropriately after surgery? A. "Have sex once a day to facilitate adjustment." B. "Seek counseling with a sex therapist." C. "Return for follow-up care in 2 weeks." D. "Have sex once a week."

Answer: B Rationale: Penile implants are often uncomfortable for the partner, and the client may be able to sustain sex longer than the partner desires. The implant requires both partners to adapt, and a sex therapist can assist the couple. Frequency of sex does not facilitate adaptation, and follow-up care is needed if there are problems.

The nurse is assessing a 65-year-old client who complains of priapism after "taking the little blue pill" 6 hours ago. What is the nurse's priority intervention for this client? A. Lubrication to prevent clothing friction B. Ice packs to reduce swelling and pain to prepare for aspiration C. Estrogen to counteract the testosterone in the Viagra D. Lidocaine to decrease penile pain

Answer: B Rationale: Priapism is a persistent penile erection unrelated to sexual stimulation that last 4 or more hours and can lead to scarring and permanent erectile dysfunction. Treatments include Ice packs to reduce swelling; surgical ligation of artery; intracavernous injection; aspiration; and surgical shunt of blood flow. Lubricants are used to lubricate the vagina for sexual stimulation, lidocaine is used for vaginal pain during or after intercourse, and hormonal therapy is used to control vaginal bleeding.

The nurse is caring for a client who has been diagnosed with primary dysmenorrhea and tells the client about which treatment for the disorder? A. "You will need to have a laparoscopy to cure the disorder." B. "Treatment is aimed at reducing symptoms." C. "You will be scheduled for an MRI to determine treatment." D. "Treatment will include surgery to correct the defect."

Answer: B Rationale: Primary dysmenorrhea is treated by reducing symptoms. Secondary dysmenorrhea is the result of an organic problem requiring diagnosis with a laparoscopy, MRI, or CT scan and then surgery to correct the problem, if appropriate.

A 16-year-old who has recently become sexually active comes to the clinic to ask about spermicides as a method of birth control and what their advantages and disadvantages are. What is the best response made by the nurse? A. "Spermicides cause very few problems, and they are almost 100% effective." B. "Spermicides are minimally effective when used alone, and do not offer protection against infection from HIV, or against any other sexually transmitted infection." C. "It is a very convenient method, and you will be able to insert the spermicide up to 4 hours before intercourse." D. "If you want an effective method, you should choose something else."

Answer: B Rationale: Spermicides must be used within 30 minutes of intercourse, have a failure rate of 21%, and do not offer protection against any sexually transmitted diseases. Telling the client to choose another method does not answer the client's question and offers unsolicited advice.

Which statement would be the most effective way to approach a family from another culture regarding the nutritional needs of their children? A. "Here is the diet plan your children should be on." B. " I would like to teach you about the nutritional requirements of your children." C. "Your children are overweight and need more exercise." D. "We are going to be changing your family's eating habits to improve the health of your children."

Answer: B Rationale: The best way to overcome racial and ethnic disparities in healthcare and well-being is through education. The other statements challenge the family's values, without offering education or allowing for family input. Such strategies have a low chance of success

A client who is a victim of intimate partner abuse attends a group therapy session. Which comment by the client indicates a desired outcome? A. "I should have kept my mouth shut and none of this would have happened." B. "I realize now that I am not responsible for the abuse and I do not deserve to be treated this way." C. "I am not afraid to be alone with my significant other even though he is the reason I am here." D. "I can't leave the situation. There is nowhere for me to go."

Answer: B Rationale: The client is demonstrating a desired outcome by stating, "I realize now that I am not responsible for the abuse and I do not deserve to be treated this way." The desired goal is for the client to verbalize awareness that they are not responsible for the abuse and that they do not deserve it. The other responses demonstrate negative outcomes. Desired outcomes would include the client openly communicating fears in regards to the abuse and demonstrating knowledge of available resources to those in abusive situations.

When interviewing a potentially violent or aggressive client, which environmental factor is most important for the nurse to consider? A. Care should be taken to ensure that other staff members do not interrupt. B. The interview should take place in a calm, quiet area to reduce stimuli. C. The client should be told that violent behavior will not be tolerated. D. Restraint devices should be in full view of the client.

Answer: B Rationale: The nurse should ensure that the interview be conducted in a quiet environment. Even minor factors, such as, loud noise can trigger aggression and violence. Reduction of interruptions is advisable but may not be totally possible. Intimidation of the client with restraints and verbal rebukes is inappropriate and may provoke violent behavior.

A spouse and his client who is perimenopausal is questioning the nurse regarding self-care during this process. The nurse plans to focus teaching for this client on which priority of care? A. Referring the client to a support group B. Reducing the risks associated with menopause C. Recommending hormonal therapy D. Stressing the importance of foot care

Answer: B Rationale: The priority of care is teaching the client lifestyle changes that can help reduce the risks associated with menopause. Referring the client to a support group may be a consideration, but is not the priority. The nurse can offer information regarding hormonal therapy, but it is the physician who makes the recommendation. Foot care is important to the woman who has diabetes.

A client with dysfunctional uterine bleeding (DUB) tells the nurse that she is having problems with sexual performance. The nurse selects sexual dysfunction as a nursing diagnosis and suspects that the dysfunction is related to which factor? A. Edema B. Fatigue C. Sweating D. Obesity

Answer: B Rationale: The woman who is bleeding heavily is losing hemoglobin and is usually fatigued, which affects interest in sex. The nurse plans interventions aimed at conserving energy in this client. Obesity, edema, and sweating are not usually associated with the lack of sexual desire in the client with DUB.

The nurse who works in a drug rehabilitation facility understands substance abuse can affect individual family members as well as the family unit as a whole. Which nursing intervention related to family is appropriate? A. Educate family members about how to confront the client regarding the client's abuse. B. Recommend community resources to family members to help them process and cope with resultant complications. C. Encourage client to apologize to family members for his or her actions. D. Educate the client about how his or her family members cause the problem of addiction.

Answer: B Rationale: When an individual suffers from addiction to illegal substances or alcohol, his or her addictive behaviors are likely to affect close family members in a number of ways. The nurse should recommend community resources to family members to help them process and cope with resultant complications.

The nurse is planning care for a client who has sustained multiple injuries from a motor vehicle crash. The nurse notes that the client and the client's family are experiencing spiritual distress. Which action taken by the nurse would be most appropriate? A. Encourage the family not to discuss the accident with the client. B. Offer to call the family minister. C. Leave the client and family alone. D. Discuss with the family the difficulties they will experience when taking the client to the home environment

Answer: B Rationale: When noticing a client or client's family in spiritual distress, it is appropriate to contact the family minister or spiritual leader. It is not appropriate to encourage the family not to discuss the accident. The family and client should be encouraged to express their feelings. For the nurse to assume and leave the client and family alone would be inappropriate as it would be more appropriate for the nurse to remain present. While it is appropriate to evaluate the needs at the home should the client be discharged, it is not appropriate to merely discuss with the family the difficulties they will face.

Which intervention is of highest priority in preventing infections in a multiple trauma victim? A. Assessment of temperature every 3-4 hours B. Washing hands before all client contact C. Providing a diet high in calories and protein D. Changing the client's dressing every shift

Answer: B Rationale: Hand washing before contact with a patient is the best way to prevent infection in a hospitalized client. Assessment of temperature is assessment, not prevention. Providing a diet high in protein promotes healing of wounds. Changing a dressing every shift also promotes healing.

The nurse is aware that changing levels of hormones and neurotransmitters may contribute to violent behavior. Which elevated level would cause the nurse to be concerned about a potential for violence in a client? A. Serotonin B. Testosterone C. Dopamine D. Cortisol

Answer: B Rationale: Higher testosterone levels may cause a deficit in serotonin levels, which, in turn, causes people to react more aggressively to annoying situations. Serotonin exerts inhibitory control over aggression. Lower levels of serotonin, not higher, are associated with more aggressive behavior. Dopamine appears to be inversely associated with aggressive behavior, meaning that low levels of dopamine may cause more aggressive behaviors. Low cortisol levels, not higher levels of cortisol, have been associated with greater antisocial behavior.

A 10-year-old client was admitted to the hospital with a gunshot wound to the abdomen sustained in a drive-by-shooting. The nurse knows that which intervention is priority when caring for a client with a gunshot wound? A. Referring the client to physical therapy for evaluation B. Monitoring for bleeding and controlling hemorrhage C. Performing wound care D. Monitoring for signs and symptoms of infection

Answer: B Rationale: Injuries need to be treated in order of severity. Priorities for the treatment of a gunshot wound include, maintenance of the airway, controlling hemorrhage, and preventing hypothermia. When caring for clients who have been assaulted nurses do focus on infection control, health maintenance, and recovery. While monitoring the wound for signs of infection, wound care, and rehabilitation are all a focus of care, they are not the priority.

The nurse is caring for a severely battered woman. Which action taken by the nurse would be inappropriate? A. Determine the immediacy of danger. B. Convey that the victim and the abuser are to blame. C. Support the victim's choice to return to the unsafe situation. D. Provide information regarding available resources.

Answer: B Rationale: It is inappropriate to suggest that the victim is to blame for the abuse. It is appropriate for the nurse to determine the immediacy of danger, provide information regarding available resources, and to support the victim's choice to return to the unsafe situation. The nurse should avoid being judgmental and support the individual's choice about whether to leave the unsafe situation or return to the abusive relationship.

A client who has been physically abused asks the nurse, "What makes people so violent toward others?" Which is the best response to this question? A. "Hormones are the primary reason for violence in men." B. "It is difficult to give one specific reason for violent behavior." C. "If women were more agreeable, there wouldn't be any violence." D. "Violence is inherited from a person's family."

Answer: B Rationale: Many theories exist concerning the motivation for violent behavior and abuse within families. Some of those theories propose that individuals are genetically predisposed to violence, while other theories discuss the influences of society and family structure. No definite causes of family violence have ever been agreed upon, but theories such as the psychopathology theory and the social learning theory lead into one another to help highlight some contributing factors to abusive behavior.

Which statement by the client could indicate a potential problem for the couple planning to use coitus interruptus? (Select all that apply.) A. "We don't have any other sex partners." B. "I really do not want to get pregnant right now, so we need a very effective method." C. "I can always pull out before I ejaculate." D. "We want a contraceptive method that is inexpensive and natural." E. "We want to have three children eventually."

Answer: B and C Rationale: Because some semen is released before ejaculation, coitus interruptus has an 18% failure rate and would not be considered a highly effective means of preventing pregnancy. Not having other sex partners and wanting children later are not relevant to this problem. Coitus interruptus is both inexpensive and natural, even if not always effective.

The nurse has been working with a teenage female client who was assaulted and robbed late one night after shopping. Which outcome indicates that the client has achieved the expected outcomes of treatment? (Select all that apply.) A. The client states that she will no longer shop. B. The client is enrolling in a self-defense class for women. C. The client talks about the event without excessive distress. D. The client states that she will shop only when there is someone to accompany her. E. The client states a plan to choose parking spaces close to a building.

Answer: B, C, and E Rationale: The client demonstrates effective coping by talking about the event without distress, making a plan for shopping, and by enrolling in a self-defense class. Not shopping at all or only with company demonstrates unresolved anxiety over the event.

The nurse is teaching a group of women with premenstrual syndrome (PMS). A client asks what the major risk factors are for developing this disorder. The nurse replies that the risk factors include: (Select all that apply.) A. heart disease. B. major life stressors. C. Depression. D. teenage women. E. Age greater than 30 years.

Answer: B, C, and E Rationale: Those most at risk for developing PMS are over the age of 30, are experiencing major life stressors, and have a history of depression. This condition is not necessarily seen in the teenage group or those with heart disease.

When conducting a health assessment, which question or statement would the nurse most likely use to elicit information about sexual concerns? A. "Why do you think you should be sexually active at your age?" B. "Following your prostate surgery, when did you first notice you had problems with sexual intercourse?" C. "Tell me about your experience with sexual function since you developed prostate enlargement." D. "Do you miss having sex?"

Answer: C Rationale: Asking the client for his experiences facilitates the client's ability to feel comfortable discussing erectile dysfunction or other sexual concerns. Asking the client when he first noticed problems is assuming that there are problems. Asking the client if he misses sex or suggesting that he is too old for sex is judgmental.

Which intervention should the nurse include when planning the care for an adolescent female who is pregnant and lives alone? A. Notify social services. B. Refer the client for welfare. C. Assess the client for strengths and resources. D. Advise the client to give the baby up for adoption.

Answer: C Rationale: Before planning care for this client, the nurse would assess the client for strengths and resources that are available to support the client in her wishes. Referring the client for welfare or social services, unless requested by the client, is a disservice to the client who is ready and able to plan her own life. A nurse does not recommend adoption to a client: if the nurse observes evidence that the client cannot care for herself or the infant, a referral might be made to social services.

In interviewing a client concerning sexually transmitted infections (STI), the nurse should recognize that which is a barrier to client disclosure? A. Nurse's use of nonjudgmental attitude B. Collecting information while the client is dressed C. Use of yes-or-no questions D. Use of a culturally sensitive approach

Answer: C Rationale: Closed-ended, yes-or-no questions are a barrier to communication with the client. Using a nonjudgmental attitude enhances communication. When talking about sexual and sensitive matters, the client may be more comfortable if dressed. Use of culturally sensitive approaches enhances communication.

The nurse is caring for a client with an endometrial implant. The client asks the nurse what happens to the implant now that she is experiencing menopause. The best reply by the nurse is that the implant: A. tends to become malignant. B. enlarges in size. C. tends to atrophy and disappear. D. increases in numbers.

Answer: C Rationale: Endometrial implants tend to atrophy and disappear after menopause since ovarian hormones no longer stimulate them. Implants do not tend towards malignancy and, with no or little hormone stimulation, will not increase in size or number.

A client has recently been diagnosed with terminal cancer. To help prevent alterations in family function, the nurse would do all actions except: A. Encouraging talking about the illness as a family. B. Connecting the family with the appropriate supportive resources C. Referring the client and family to a psychologist D. Informing the client and family of the challenges associated with the illness early in the process

Answer: C Rationale: Families who are made aware of the challenges associated with illness early in the process may benefit from having additional time to consider and plan for some of the upcoming circumstances. Successful coping with caregiver and family challenges comes as a result of accepting the illness, whether it is temporary or chronic, and then working to keep the family unit healthy. Talking about the illness as a family can be extremely beneficial, as can connecting the family with the appropriate supportive resources. Referring the client and family to a psychologist is not the nurse's role.

The nurse is instructing a group of families regarding positive coping methods when faced with stress. What would the nurse include in the teaching? A. Decision-making by one family member B. Families exhibiting minimal violent behaviors C. Families with open communication among members D. Families with no boundaries between members

Answer: C Rationale: Families with open communication are families with the strength to cooperate and allow for growth of the group. Decision-making by one member may be considered belittling to the rest of the group. Any violence in the family group is dysfunctional. Families with no boundaries foster codependence in the group.

A 30-year-old African client is a survivor of female genital mutilation (FGM). What assessment complications would the nurse expect to find with this client? A. Abnormal Pap smear B. Cervical cancer C. Chronic UTIs D. Bilateral nipple discharge

Answer: C Rationale: Female circumcision, also known as female genital mutilation (FGM) or female ritual cutting is a dangerous practice that is common in parts of Africa. Removal of the clitoris may or may not be accompanied by removal of the labia and closure of the vaginal entrance except for a small opening. Long-term medical complications include urinary incontinence, chronic urinary tract infections, vaginal scarring, pain syndromes, infertility, and sexual dysfunctions.

Which behavior does the school nurse recognize as an indicator that a school-age child has been physically abused? A. The child acts obediently when a parent scolds the child to be quiet. B. The child sits quietly with a friend in the schoolyard instead of playing kickball. C. The child bullies other children and threatens them to "keep quiet about it." D. The child tells other children that they will get a "time-out" if they continue to misbehave.

Answer: C Rationale: It is common for children to model the behaviors of parents, siblings, other adults, or actions they see on television. Therefore, children have a high likelihood of adopting abusive tendencies perpetrated by their parents or siblings. Acting obediently when being scolded indicates appropriate discipline by the parent. There may be many reasons why the child does not want to participate in a physical sport. An abused child may be withdrawn and isolated from peers. Nonphysical interventions such as time-outs are more effective than spanking at modifying unwanted behavior.

The nurse is assigned for the day to a unit whose clients are diagnosed with AIDS and complains about being on this unit. The nurse realizes which of the following about the assignment? A. Another nurse will report the fellow caregiver's complaints. B. The nurse will refuse to provide care for these clients. C. The nurse needs to deal with feelings related to this group of clients. D. The nurse needs to ask to be reassigned to another unit.

Answer: C Rationale: It is important for nurses to explore personal attitudes and feelings about clients who are different from themselves. Nurses cannot abandon clients or refuse to care for them based on dislike. The nurse needs to be aware of personal prejudices so that appropriate care can be given to all. The nurse may or may not report the fellow caregiver's complaints; however, all nurses have the responsibility to provide client care with respect. The nurse who is refusing to care for this group of clients should discuss this problem with management and it is not the responsibility of fellow nurses.

A mother from Latin America brings her febrile baby to the primary care provider because she thinks her baby's body is out of balance. The mother tells the nurse that she also plans to consult a curandero. The best course of action on the part of the nurse is to: A. Explain to the mother that curanderos use ineffective folk medicine. B. Provide teaching and ensure the mother understands the use of the medication. C. Tell the mother that the baby may have seizures if the high fever continues. D. Tell the mother that acetaminophen is stronger magic than the curandero's magic.

Answer: C Rationale: It is important for the nurse to teach the mother that the child could have severe consequences if the medication is not given. Providing teaching but not discussing the risk of seizures is not the best response because it does not teach the mother why the medication is so important. Statements that are disrespectful of the client's culture will likely alienate the mother and potentially result in harm to the child.

A client is interested in using female condoms as a method of preventing pregnancy and asks the nurse if they have any disadvantages. What is the nurse's best response? A. "The female condom is very effective, and I'll write a prescription for you." B. "The female condom provides good protection against pregnancy but offers no protection against sexually transmitted infections (STI)." C. "The female condom may be difficult to insert and may be uncomfortable to both partners." D. "The female condom is made of latex and presents a problem if you have a latex allergy."

Answer: C Rationale: Made of polyurethane, the female condom does not require a prescription but can be difficult to insert and may cause discomfort to both partners. It is effective against STI and pregnancy.

A nurse who provides culturally competent family-centered care acknowledges that this requires cultural awareness. Cultural awareness in family-centered care includes all except: A. Seeking additional information when caring for clients whose cultural beliefs are unfamiliar. B. Gaining knowledge about the cultures predominantly served in the nurse's clinical setting. C. Becoming an expert about every culture. D. Acknowledging the numerous variations of family structures, while avoiding making assumptions and judgments.

Answer: C Rationale: Proficient nursing care requires cultural awareness. The nurse is not expected to become an expert about every culture. The nurse should strive to become knowledgeable about the cultures predominantly served in his or her clinical setting and seek additional information when caring for clients whose cultural beliefs are unfamiliar. Nurses should also acknowledge the numerous variations of family structures, while avoiding making assumptions and judgments.

The nurse is caring for an elderly client who has been admitted with a recent fall. The admission assessment revealed several bruised areas on the back and legs. During the interview with the caregiver, the caregiver states, "I don't know what to do with her when I go to work during the day so I leave her home alone." What is the most appropriate action for the nurse to take? A. Encourage play therapy. B. Suggest art therapy. C. Provide resource information on adult day cares. D. Threaten to contact the authorities.

Answer: C Rationale: Providing resource information on adult day cares is most appropriate in this situation. The client's caregiver is expressing concern about leaving them home alone and an adult day care may give the caregiver a safe option for the times the caregiver is at work. Play therapy most commonly helps children play out traumatic themes, fears, and distorted beliefs. It is a nonthreatening way to process thoughts and feelings associated with the abuse, both symbolically and directly. Art therapy provides an opportunity to express feelings for which there are no words. While elder abuse is a reportable event, the lack of the caregiver's knowledge of resources has attributed to the safety issue.

Seldenafil (Viagra) is prescribed for a client with erectile dysfunction. When reviewing the client's record and the nurse questions the prescription if which clinical manifestation is noted in the record? A. Neuralgia B. Use of multivitamins C. Use of nitroglycerin D. Insomnia

Answer: C Rationale: Seldenafil enhances the vasodilation effect of nitric oxide in the corpus cavernosum of the penis, thus sustaining an erection. Because of the medication's effect, it is contraindicated with concurrent use of organic nitrates and nitroglycerin. Neuralgia and insomnia are side effects of seldenafil. There is no contraindication when taking vitamins.

A 13-year-old client has started her menstrual cycle 6-months ago. The frustrated client complains, "my period never comes on at the same time!" What is the best response made by the nurse? A. "Do you have cramping before it comes on?" B. "Are you taking any birth-control pills?" C. "Wearing panty liners every day until your cycle becomes regular is an option so your clothes won't get stained." D. "Make sure you use condoms whenever you have sex to prevent STIs and pregnancy."

Answer: C Rationale: Teenage girls may have irregular menstruation initially, which can lead to embarrassment because of stained clothing. Girls should also be counseled regarding the variety of feminine hygiene products available (e.g., sanitary pads and tampons) so that they can make intelligent choices.

The nurse is planning an educational class for a group of 16 year-olds at the local high school. Regarding the transmission of sexually transmitted disease (STD), the nurse plans to teach the students that the best method of preventing STDs is: A. reducing the amount of alcohol intake. B. seeking medical help with early symptoms. C. practicing abstinence. D. seeking testing for one member of the partnership.

Answer: C Rationale: Teens should be taught that abstinence is the best method of preventing STD. Alcohol does not prevent or encourage STD, but it can affect judgment. Seeking medical help with symptoms will not prevent STDs but may help prevent the spread of the infection. Both parties should be tested before they engage in a sexual relationship.

The nurse is planning care for a client who is experiencing erectile dysfunction. The nurse selects which nursing diagnosis as most appropriate for this client after the initial assessment? A. Risk for Impaired Attachment B. Autonomic Dysreflexia C. Situational Low Self-Esteem D. Defensive Coping

Answer: C Rationale: The client with erectile dysfunction often thinks of himself as being less of a man due to the dysfunction. The nurse plans care to help restore self-esteem. Defensive coping may exist in some clients, but low self-esteem is more common. Autonomic dysreflexia is a complication of spinal shock. Risk for impaired attachment does not impact the client's ability to have an erection.

A nurse is caring for a family in a rural healthcare setting when the parents tell the nurse that they do not have enough money to pay for groceries. Who does the nurse collaborate with to help the family's financial problems? A. The parent's employer B. The home health agency C. The medical social worker (MSW) D. The family physician

Answer: C Rationale: The nurse will collaborate with the medical social worker (MSW) to aide in providing the family with financial resources. The nurse may collaborate with the physician, however, not for financial guidance. The nurse will not collaborate with the parent's employer or the home health agency

The nurse is working with a family to develop a care plan to identify potential resources in the community that match the family's needs for support. The nurse uses a collaborative approach which includes: A. Assessing the family for readiness to learn. B. Educating the family about health concerns related to genetic disorders. C. Working with a medical social worker (MSW) to provide the family with needed financial resources. D. Establishing an appropriate nursing diagnosis for the family.

Answer: C Rationale: The nurse working with a family to develop a care plan identifies potential resources in the community that match the child's and the family's needs for support. The nurse will collaborate with the family to discuss those resources and to select the ones that are acceptable to the family, to increase the likelihood that the family will follow through with the plan. In some cases it may be necessary to collaborate with a multidisciplinary team, including social workers, to help the family obtain assistance to overcome, for example, financial struggles. All other choices are independent interventions, not collaborative.

The nurse is interviewing a client couple for an infertility work-up. Which topic will the nurse plan to discuss with the couple? A. Whether the couple has medical insurance B. Whether the male has seafood allergies C. How infertility is affecting their lives D. Whether the female works outside the home

Answer: C Rationale: The psychological, cultural, and social ramifications of infertility can be extensive. The nurse ascertains the need for counseling and support during treatment. Medical insurance, allergies to seafood, and the female who works outside the home are not relevant to the question.

A client with three children has come to the family planning clinic asking about a birth control method that is sanctioned by the Roman Catholic Church. What is the best recommendation suggested by the nurse? A. Billings or cervical assessment method B. Ovulation testing kit C. Symptothermal method D. Basal body temperature (BBT) method

Answer: C Rationale: The symptothermal method combines cervical mucus and BBT measurements and results in a lower failure rate than single assessments of the fertile period. Ovulation testing kits do not give enough warning of ovulation to prevent pregnancy.

A nurse came to work with a black eye and a swollen lip. Coworkers have noticed that the partner calls the nurse at least 10 times during a 12-hour shift. The nurse has refused all invitations to go out with coworkers, saying that the partner will be there after work and doesn't like to wait. Which action taken by the coworkers would be most helpful? A. Convince the nurse to leave the partner. B. Encourage the nurse to get a restraining order against the partner. C. Encourage the nurse to talk to a professional. D. Enlist the parents' aid in getting the nurse away from the partner.

Answer: C Rationale: Encourage the nurse to talk to a professional. Nurses encourage the client to accept help in seeking an abuse-free living situation, but the decision ultimately lies with the client. Some individuals will not be ready to seek help, and while the nurse may disagree with this decision, he must refrain from judgment and be respectful of the client's decision. All nurses can do in these situations is offer assistance and resources, the victim will then know that help will be available if it is needed in the future. Trying to convince abused adults to leave their abuser does not empower the adult. Friends and coworkers should provide support without telling the nurse what to do. Encouraging the nurse to get a restraining order against the partner is inappropriate because a restraining order may actually increase the violent behavior of the partner. Involving the parents may complicate the situation and result in more abuse, which further isolates the nurse from family and friends.

The nurse learns that a male client is HIV positive. What should the nurse do when providing care to this client? A. Avoid direct contact with the client. B. Wear a gown and gloves at all times. C. Follow standard precautions. D. Ask the client if he has a girlfriend.

Answer: C Rationale: The nurse's reaction to the client's HIV positive status should be one of non-prejudice. The only choice that would demonstrate non-prejudice would be following standard precautions, which are implemented for all client care. Avoiding direct contact with the client, asking the client if he has a girlfriend, and wearing a gown and gloves at all times would indicate that the nurse has biased feelings against the client's HIV status and possible sexual orientation.

Severe facial injuries, such as those resulting from going through the windshield of a car, increase the risk for all of the following. Which would the nurse assess for first? A. Hemorrhage B. Contusions C. Airway obstruction D. Fractures

Answer: C Rationale: The first priority is always the airway. Assessing the airway and initiating interventions are the first steps in managing a client who has been in a motor vehicle crash. Although checking for hemorrhage, contusions, and fractures is important, a patent airway is the number-one priority for survival.

The nurse is explaining treatment options to a client with erectile dysfunction (ED). The nurse knows the client understands that which treatment draws blood into the penis and sustains an erection with a ring? A. Penile implant B. An O-ring alone C. Inflatable prosthesis D. Vacuum constriction device (VCD)

Answer: D Rationale: A VCD draws blood into the penis and sustains the erection by placement of the O-ring at the base of the penis. An O-ring alone does not bring blood to the penis, but works for the client who is able to attain an erection. Penile implant and inflatable prosthesis are surgical procedures.

What indicates to the nurse that the client who recently emigrated from India has experienced acculturation? A. The client speaks very little English. B. The client lives in a neighborhood that is predominantly Indian. C. The client shops at a grocery store owned by people from India. D. The client attends a community center across town to make new friends.

Answer: D Rationale: A person experiences acculturation when they begin to adapt or borrow habits of the new culture. The other behaviors are examples of a client who may feel comfortable only in the client's Indian culture.

The nurse is planning care for a client who has witnessed a violent assault. Which is a key component of crisis intervention that the nurse should utilize at this time? A. Assist the client in forgetting the crime. B. Identify the client's maladaptive coping mechanisms. C. Teach the client to handle similar future events. D. Identify the client's coping patterns and then offer support.

Answer: D Rationale: Assisting the client to identify coping patterns and then supporting the client is essential to managing a crisis. Identifying the client's maladaptive coping patterns may be beneficial after identifying strengths, but not initially. Assisting the client to forget is not a therapeutic intervention for crisis management. Teaching the client how to handle similar future events is appropriate after the current crisis has abated.

An 82-year-old client is seen in the clinic. While the nurse is palpating the client's breast, the client complains of tenderness in the left breast. The nurse knows what about this assessment finding? A. This is a normal finding. B. This reflects enlarged axillary nodes. C. This is a result of an infection in the pectoral nodes. D. The client may have cancer; notify the physician.

Answer: D Rationale: Breasts should feel smooth, firm, and elastic. Many women have nodularity or lumpiness that is uniform in both breasts (fibrocystic changes related to cyclic hormones). Tenderness, in premenopausal women may be related to premenstrual fullness, fibrocystic changes, inflammation. Tenderness has also been associated with cancer in the older post-menopausal female. Tenderness, erythema, and heat may be seen with mastitis or inflammatory breast cancer. All other assessments are normal.

A nurse has implemented a plan of care stressing health promotion for a family. Planned nursing outcomes that demonstrate health promotion include all except the following: A. Family will meet the needs of its members during developmental transitions. B. Family will display or describe actions to manage stressors that tax family resources. C. Family members will demonstrate actions to improve the overall health and social competence of the family unit. D. Each family member is up to date with all vaccinations.

Answer: D Rationale: Each family member being up to date with all vaccinations is an example of an achieved outcome while all other choices are planned nursing outcomes.

A client who is a victim of elder abuse has been attending counseling sessions with their family. The nurse evaluates that an abusive family member has learned positive coping skills when which statement is made? A. "I am sorry for the abuse; it won't happen again." B. "I will make sure that my parent's needs are met." C. "I will need to change my behavior when my parent moves in with us." D. "Now that I know what my resources are, I think I can do a better job of caring for my parent."

Answer: D Rationale: Elder abuse can occur when family are expected to care for the aging parent. This causes frustration, overextension, and sometimes is a financial burden. Stating that the abuser will use assistance from resources is a positive action toward behavior change. Stating that they will meet the needs of the client, that they are sorry, or that they need to change behavior are not demonstration of a positive change; it is simply lip service and a hallmark response by habitual abusers.

A 53-year-old woman asks the nurse if there are any definitive laboratory tests that would show that she has entered menopause. The nurse responds that which test is done to clarify the diagnosis? A. Estrogen levels B. Complete blood count C. Blood, urea, nitrogen (BUN) levels D. Follicle-stimulating hormone (FSH) level

Answer: D Rationale: FSH blood testing can be done after the woman has gone one year without a menstrual cycle. If the FSH is high, a diagnosis of menopause can be made. Complete blood count, estrogen levels, and BUN blood tests are not diagnostic for menopause.

A nurse is working with a client in a primary care clinic who is a stay-at-home mother to three young children. The nurse uses which nursing intervention to promote the prevention of stress in this client? A. Recommending the client to work outside of the home for social interaction. B. Recommending the use of anti-anxiety medications to aide in managing stress. C. Recommending the client place her children in daycare for one day a week in order to find time for herself. D. Recommending a community activity that promotes exercise.

Answer: D Rationale: Family wellness and health promotion strategies involve empowering clients to make beneficial changes in their lives. For this client, the nurse might suggest a community activity that promotes exercise for stress reduction. Recommending the use of anti-anxiety medications is inappropriate. Recommending the client to work outside of the home or to place her children in daycare is also inappropriate because these options may not be financially possible for the client and the client may not desire that change.

Which intervention will the nurse initiate for the family of a client with a terminal illness who wishes to be at home for end-of-life? A. Refer the family for counseling before allowing the client to go home. B. Notify the physician of the client's wishes. C. Point out the hardships of having a dying client in the home. D. Refer the family to hospice care.

Answer: D Rationale: Hospice services provide care to the family and to the client who prefers to die in the home. Pointing out the hardships to the family is not the role of the nurse or the physician unless there is a fear the client will not receive appropriate care. Referring the client to counseling before there is evidence of a need is not appropriate. The physician is not involved in nursing decisions.

The care plan formulated with a client includes the goal: client describes self as a rape survivor. The nurse reviewing the care would be aware that this goal would be inappropriate for which client? A. Client in the emergency department with a panic attack that the client relates with a rape 6 months ago B. Client in individual therapy 1 month after a rape C. Client in primary care setting 3 months after a rape D. Client in the emergency department immediately after the rape

Answer: D Rationale: Immediately after the rape is too soon to expect the client to see herself as a survivor. The goals for this client might be to have the client make choices about treatment or to identify current feelings. Clients who are 1, 3, and 6 months after the rape might consider themselves as survivors. However, this does not mean they are free of the fears and feelings related to the rape.

The nurse teaches a client who is to undergo a vaginal hysterectomy for dysfunctional uterine bleeding. The nurse knows the client has met teaching goals when she makes which statement? A. "I will continue to take my oral contraceptives." B. "I will continue to have menstrual periods." C. "I will no longer have ovaries." D. "I will not begin menopause because only the uterus will be removed."

Answer: D Rationale: In a vaginal hysterectomy, only the uterus is removed. The ovaries are left in place so that the hormonal cycle continues and menopause does not ensue. The client will no longer have menstrual periods and there is no need to continue oral contraceptives since pregnancy cannot occur

The nurse is conducting an assessment on an adult victim of a recent sexual assault. Which statement would hinder the therapeutic relationship between the nurse and the victim? A. "You may feel anger, guilt, fear or resentment, but these are very normal reactions." B. "You handled the attack as well as you could; you survived." C. "You didn't do anything to cause the attack, and it's not your fault you were raped." D. "You may want to have an abortion if you find out you are pregnant."

Answer: D Rationale: Mentioning abortion hinders the therapeutic relationship because it advises the client to make a personal choice that may be against her values and beliefs. This statement would block further communication about the options that are available to the client. The therapeutic relationship is facilitated by reassuring the client that she acted as rationally and appropriately as anyone could in a life-threatening situation, by letting the client know that the nurse understands the emotions one commonly feels following a violent attack, and by reminding the client of her innocence. Many victims think they could have avoided the rape if they had acted differently.

An assault victim arrives at the hospital seeking treatment for several lacerations and broken bones. The nurse anticipates that in addition to requiring the care of a physician, a nurse, and orthopedic care the client may also benefit from receiving which discipline? A. A pulmonologist B. A cardiologist C. Anger management training D. Counseling and spiritual guidance

Answer: D Rationale: Multidisciplinary approaches are also necessary when working with victims of assault. Depending on the injuries inquired different disciplines may be required. Victims may require counseling and spiritual guidance. There is no reason that indicates that this victim needs anger management and at this time there is no indication that this victim would require a cardiologist or pulmonologist.

During the examination portion of her annual checkup, a 55-year-old client has several new complaints. Which subjective symptoms of menopause would the nurse expect to find during data collection? A. Rise in vaginal Ph B. Decreased skin elasticity C. Hair growth on the upper lip D. Night sweats

Answer: D Rationale: Night sweats is the only symptom that is subjective, reported by the client. Facial hair, decreased skin elasticity, and a rise in vaginal pH are all objective signs that can be observed by the nurse.

A competent nurse understands that collaborative interventions assist families with navigating through challenges or difficult circumstances. An example of a collaborative intervention for clients with alterations in family health is: A. Listening to the challenges new parents describe during an infant's first health visit. B. Educating the client regarding family centered care. C. Give information or correct misconceptions regarding health, illness, treatment, and prevention. D. Referring the client and their family to experts who specialize in social work, psychology, or mental health care when necessary.

Answer: D Rationale: Nurses can employ both independent and collaborative interventions to assist families with navigating through challenges or difficult circumstances, as well as to promote the optimal use of each individual's strengths. A collaborative intervention includes referring the client and their family to experts who specialize in social work, psychology, or mental health as necessary. All other answer choices are important family-centered interventions, however, they are independent interventions rather than collaborative.

A client with suspected menorrhagia is being assessed by the nurse at the clinic. What is the priority assessment the nurse must make in an effort to determine the cause of the disorder? A. "Do you exercise vigorously?" B. "Have you had the flu recently?" C. "Have you increased your sodium intake?" D. "Are you taking anticoagulants?"

Answer: D Rationale: The client with menorrhagia (excessive or prolonged menstruation) should be evaluated for thyroid disorders, use of anticoagulants, and other uterine disorders. Intake of sodium and the flu are not associated with menorrhagia. Strenuous exercising is associated with amenorrhea.

The nurse notices that the young adult client from another culture consults with the parent before making any decisions. Which action by the nurse would be most important at this time? A. Take the client out of the room and continue the session without the parent. B. Ask the parent to leave the room so that the client can make decisions. C. Ignore the parent and repeat the questions, looking directly at the client. D. Accept the behavior of the client and the parent.

Answer: D Rationale: The nurse must consider the family roles of clients from another culture and adapt care to the client. The other actions would demonstrate a lack of understanding by the nurse of the differences of the client's culture.

A nurse working in a well-child clinic asks the parent of an infant to discuss the support systems that the family has. This nurse is: A. Asking questions that are not pertinent to the client's care. B. Acting in the role of mental health nurse. C. Performing a risk assessment. D. Performing a family assessment.

Answer: D Rationale: The purpose of family assessment is to determine the level of family functioning, clarify family interaction patterns, identify family strengths and weaknesses, and describe the health status of the family and its individual members. Family assessment gives an overview of the family process and helps the nurse identify areas that need further investigation. The nurse is asking questions that are pertinent to the client's care and is not acting in the role of mental health nurse. This nurse is performing a family assessment, not a risk assessment.

A male nurse is caring for a female client from another culture. As the nurse enters the room, the client avoids eye contact and moves to the other side of room. The nurse's best response is to: A. Perform the care without acknowledging the client's behavior. B. Ask a female nurse to perform care. C. Invite a male family member to be present during care. D. Before touching the client, explain the procedures and ask permission to do them.

Answer: D Rationale: The response showing the nurse is respecting the client's practices is one that shows a respect for the personal boundaries of the client. There is no need for a male family member to be present or for a female nurse to give care when performing noninvasive procedures. Ignoring a client's behavior and nonverbal communication is not therapeutic.

A client has been diagnosed with trichomoniasis vaginitis. The nurse explains during client teaching that this infection can affect fertility by: A. increasing the temperature inside the vagina, which decreases the motility of the spermatozoa. B. utilizing the glycogen in vaginal secretions, leaving no nutrients for spermatozoa. C. creating a blockage of the fallopian tubes that prohibits spermatozoa from reaching the ovum. D. decreasing the pH of the vaginal secretions, thereby destroying most spermatozoa

Answer: D Rationale: Vaginal fluid pH is slightly alkaline, as is semen. Spermatozoa cannot survive in an acidic environment. This disorder does not use glycogen, block the fallopian tubes, or increase the temperature inside the vagina.

The nurse is teaching a client about the risk of toxic shock syndrome associated with diaphragm use. The nurse knows the client understands the teaching by which statement? A. "I will leave the diaphragm in for 36-48 hours after intercourse." B. "I will avoid using soap to clean the device." C. "I will wear latex or rubber gloves when handling the device." D. "I will seek treatment of any vaginal infection before reusing the device."

Answer: D Rationale: When using a diaphragm, the client is taught to seek medical attention for any vaginal infection before re-using the device, wash the hands with soap and water prior to handling the device, remove the device within 24 hours of intercourse, and to clean the device with soap and water between usages.

A female client with genital warts caused by human papillomavirus (HPV) asks the nurse what future tests will be needed to monitor this disease. The nurse recommends a yearly: A. breast exam and mammogram. B. stool for occult blood. C. complete blood count (CBC) to detect infection. D. pelvic exam and PAP smear.

Answer: D Rationale: Women with HPV genital infection are advised to have an annual pelvic exam and PAP smear, since there is increased risk of cervical cancer. While a breast exam and mammogram are recommended, they are not screenings for cervical cancer. Stool testing for occult blood and CBC will not detect cervical cancer.

When discussing responsible sexual behavior with a group of young adults, the nurse would emphasize: A. the use of animal skin condoms. B. oil-based lubricants for comfort and protection. C. birth control medications to prevent sexually transmitted infections (STIs). D. remaining in a long-term monogamous relationship.

Answer: D Rationale: Young adults need to be cautioned against multiple sexual partners as a way to prevent STIs. Animal skin condoms allow for the HIV virus to pass through the skin. Oil-based lubricants can damage a condom. Birth control medications do not prevent STIs.

Which population groups are most likely to be victims of assault and homocide? A. Older adults living alone B. Children in elementary schools C. Adolescent females in high school D. Young adult male gang members

Answer: D Rationale: Adolescents and young adults may be the group likeliest to commit and be victimized by acts of assault and homicide. Although violence has become more prevalent in schools, the highest homicide rates and victims of violent crime are seen in older teen and young adult males. Although older adults and adolescent females are vulnerable to violent crimes, the highest homicide rates and victims of violent crime are seen in older teen and young adult males.

The nurse is aware that which statement best describes peritoneal lavage? A. A scan done to determine if there are injuries to the brain and spinal cord. B. Measures the amount of alcohol in a client's blood stream. C. Measures the amount of cocaine in a client's blood stream. D. A catheter is placed into the peritoneal cavity to determine if there is a presence of blood.

Answer: D Rationale: Diagnostic peritoneal lavage determines the presence of blood in the peritoneal cavity, which may indicate abdominal injury. A local anesthetic (such as lidocaine) is injected subcutaneously, and a small incision is made in the lower abdomen. A catheter is placed into the peritoneal cavity, and any free blood is aspirated. If 10 mL of blood is found, the client is taken to the operating room for exploratory surgery. If no free blood is aspirated, 1 L of a warm isotonic solution (Ringer's solution or normal saline) is rapidly infused into the peritoneal cavity and then allowed to drain by gravity. If the solution returns pink and is found to have a red blood cell count of 100,000 mm3, a white blood cell count of >500, or bile, food, or feces, the test is considered positive and the client is taken to the operating room for exploratory surgery. A blood alcohol level is used to measure the amount of alcohol in a client's blood stream. A drug screen is used to measure the amount of cocaine in a client's blood stream. Magnetic resonance imaging (MRI) is a scan that can determine if there are injuries to the brain and spinal cord.

A 17-year-old high school student who was recently raped is reluctant to discuss the event. She can no longer use tampons during her period because she becomes dizzy and nauseated when trying to insert them. She states that she will never have another boyfriend because "I'm ruined." Which nursing diagnosis is most appropriate for this client? A. Rape-trauma Syndrome: compound reaction B. Sexual Dysfunction C. Post-trauma Syndrome D. Rape-trauma Syndrome: silent reaction

Answer: D Rationale: The client is unable to talk about the trauma, has developed a phobic reaction to tampons, and is renouncing future relationships with men. Rape-trauma syndrome: compound reaction indicates reactivation of a physical or mental illness or use of addictive substances to cope with the trauma. The client is not displaying symptoms such as nightmares, hypervigilance, insomnia, panic attacks, flashbacks, or intrusive memories that are associated with a diagnosis of post-traumatic stress disorder (PTSD). There are no indications of a physical inability that would limit sexual activity.

Which nursing diagnosis would be priority for a homosexual client who has been repeatedly physically assaulted by the partner? A. Chronic low self-esteem related to guilt and shame for being a victim of abuse B. Powerlessness related to feelings of dependence on significant other C. Social isolation related to control by the significant other and feelings of inadequacy D. Risk for injury related to history of abuse by significant other

Answer: D Rationale: The safety of the client is the priority diagnosis. The greatest predictor of continued violence is the previous history of violence by the partner. Although powerlessness related to feelings of dependence on the significant other is an appropriate diagnosis, a concern for safety is the number-one priority. Chronic low self-esteem related to guilt and shame for being a victim of abuse may be appropriate for this client, but safety is the first concern. Social isolation related to control by the significant other and feelings of inadequacy may be an appropriate diagnosis for this client, but a threat to safety would supersede this diagnosis

Which is the most significant assessment finding in a client with major trauma following a motor vehicle accident? A. O2 saturation B. Level of orientation C. Pulse rate D. Ability to speak

Answer: D Rationale: Using the ABCs, the client's ability to speak indicates an open airway. While the other options are important assessments, they are not directly indicative of the presence of a patent airway.

There are several non-modifiable factors that can be associated with the occurrence of violence. Which comment made by the student nurse indicates the need for further instruction? A. "Some environmental factors increase the risk for violence in youth." B. "Patterns of violence evolve over a person's lifetime." C. "Mental health alone is not a predictor of future violent behavior." D. "Genetics plays a primary role in the manifestations of violence and anger."

Answer: D Rationale: While genetics is found to play a role in whether an individual becomes violent, environment is often a co-factor in its manifestation. Examples of environmental factors that may affect whether a person becomes violent include prior abuse and exposure to violence

A client is admitted to the clinic with a nursing diagnosis of Acute Pain in her pelvis region. When taking a sexual history for a female client, the nurse recognizes that which factor puts the client at risk for sexually transmitted disease (STD)? (Select all that apply.) A. Current monogamous relationship B. Use of oral contraceptives C. 23-year-old client D. Report of anal intercourse E. Partner has an STD

Answer: D and E Rationale: Because it frequently involves tissue trauma that facilitates invasion of pathogens, anal intercourse is considered a high-risk sexual behavior, as is having intercourse with a partner who is infected with an STD. Use of oral contraceptives, monogamous relationships, and age of 23 years are not risks for STD.