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Questions 158

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Question 1 of 5

The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks' gestation. An appropriate response by the nurse would be:

Correct Answer: B

Rationale: This response is nontherapeutic because it belittles the client's response and gives a meaningless rationalization. This response acknowledges the client's feelings and demonstrates the therapeutic offering of self by the nurse. This response is nontherapeutic because it does not focus on the client's feelings and offers false reassurance. This response is nontherapeutic because it belittles the client's feelings and offers her advice.

Question 2 of 5

A 4-year-old child has Down syndrome. The community health nurse has coordinated a special preschool program. The nurse's primary goal is to:

Correct Answer: B

Rationale: The primary goal for a child with Down syndrome is to facilitate optimal growth and development through tailored interventions.

Question 3 of 5

The surgical nurse is preparing a patient for surgery on the lower abdomen. In which position would the nurse most likely place the client for surgery on this area?

Correct Answer: A

Rationale: The lithotomy position is used for lower abdominal surgeries (e.g., gynecologic procedures) to provide access to the pelvic area. Sim's (
B) is for rectal exams, prone (
C) for back surgeries, and Trendelenburg (
D) for shock or upper abdominal access.

Question 4 of 5

Which statement by the parent of a child with sickle cell anemia indicates an understanding of the disease?

Correct Answer: C

Rationale: Sickle cell anemia increases dehydration risk due to impaired blood flow, especially in heat. Extra fluids in summer prevent crises. Pain is due to vaso-occlusion, not excess RBCs, and skiing poses risks.

Question 5 of 5

A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:

Correct Answer: B

Rationale: Impaired communication refers to decreased ability or inability to use or understand language in an interaction. In sensory-perceptual alterations an individual has distorted, impaired, or exaggerated responses to incoming stimuli (i.e., a hallucination, which is a false sensory perception that is not associated with real external stimuli). An altered thought processes problem statement is used when an individual experiences a disruption in cognitive operations and activities (i.e., delusions, loose associations, ideas of reference). In impaired social interaction, the individual participates too little or too much in social interactions.

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