Extract:

Question 1 of 5

The nurse talks with a child who has been sexually abused by a family member. The child asks the nurse, 'If I tell you something, will you tell anyone my secret?' Which response by the nurse to the client is appropriate?

Correct Answer: D

Rationale: Nurses are mandated reporters and cannot promise confidentiality in cases of abuse, as reporting to authorities is required to protect the child. This response is honest and maintains trust while adhering to legal and ethical obligations.

Question 2 of 5

The nurse provides care for a client diagnosed with Korsakoff psychosis. Which assessment finding does the nurse expect?

A. The client's blood pressure is 180/96 mm Hg. B. The client has right-sided weakness. C. The client has tinnitus. D. The client invents elaborate, improbable events.

Correct Answer: D

Rationale: Korsakoff psychosis, often linked to chronic alcoholism, is characterized by confabulation, where clients invent elaborate but false events to fill memory gaps. Hypertension, weakness, or tinnitus are not specific to this condition.

Question 3 of 5

The nurse is assessing a client who is a polysubstance abuser, with fentanyl being one of the drugs most frequently used. Which physiological symptoms are suggestive of fentanyl intoxication? Select all that apply.

A. diarrhea B. nausea C. urge to urinate D. anxiety

Correct Answer: B

Rationale: Nausea is a common symptom of fentanyl intoxication. Diarrhea, urge to urinate, and anxiety are not typical physiological signs.

Question 4 of 5

A new mother is trying to decide whether to have her baby boy circumcised. The nurse should make which statement to assist the mother with making the decision?

A. Discuss the procedure with the male members of your family.' B. Circumcision is a difficult decision, but your primary health care provider is the best, and it's better to get it done now than later.' C. You know they say it prevents cancer and sexually transmitted infections, so I would definitely have my son circumcised.' D. Circumcision is a difficult decision. Here, read this pamphlet that discusses the pros and cons, and we will talk about any questions that you have after you read it.'

Correct Answer: D

Rationale: Informed decision making is the strategic point when answering this question. The nurse should provide educational materials and answer questions pertaining to the education of the mother. Providing written information to the mother will give her the information she needs to make an educated and informed decision. The nurse's personal thoughts and feelings should not be part of the educational process. The remaining options are not well focused on answering the mother's concerns.

Question 5 of 5

The nurse is caring for an 11-year-old child who has been physically abused. Which therapeutic action should the nurse include in the plan of care?

A. Encouraging the child to confront the abuser B. Providing a care environment that fosters trust C. Teaching the child to make wise choices when faced with possible abuse D. Reinforcing for the child that not all adults are capable of abusing children

Correct Answer: B

Rationale: Providing a safe and trusting environment is critical for a child who has experienced physical abuse, as it helps the child feel secure and supported, facilitating emotional healing. Encouraging the child to confront the abuser is inappropriate and could be traumatic, especially for a young child. Teaching the child to make wise choices in potentially abusive situations places an unrealistic burden on the child, who may not have the capacity to protect themselves. Reinforcing that not all adults are abusive is less immediate and does not directly address the child's need for a safe and trusting care environment.