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Questions 227

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Extract:


Question 1 of 5

A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:

Correct Answer: B

Rationale: Counseling by a rape crisis nurse specialist is a form of crisis intervention, providing immediate support to address the trauma. It is not merely assessment, empathy, or intrusion. Coordinated Care

Question 2 of 5

The wife of a man who is comatose following a head injury asks the nurse if she should visit him since he is unresponsive. How should the nurse reply initially?

Correct Answer: C

Rationale: Presence of loved ones may provide comfort and stimulate awareness in comatose patients, supporting family involvement. Other responses discourage visitation.

Question 3 of 5

A client with mastoiditis has a left mastoidectomy with tympanoplasty. The nurse should observe the client for signs of damage to the sixth crania nerve, which include:

Correct Answer: B

Rationale: The sixth cranial nerve (abducens) controls lateral eye movement, so damage would result in an inability to look laterally.

Extract:

When a patient return from the recovery room following a subtotal thyroidectomy, the nurse should immediately


Question 4 of 5

inspect the incision.

Correct Answer: D

Rationale: Thyroid surgery sometimes results in accidental removal of the parathyroid glands. A resultant hypocalcemia may lead to contraction of the glottis, causing airway obstruction; edema also causes obstruction. Having a tracheostomy set ready is critical.

Extract:


Question 5 of 5

A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which staff member should the charge nurse assign the client?

Correct Answer: D

Rationale: The RN is responsible for teaching and assessment associated with discharge and these activities cannot be delegated to the others listed.

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