Exam and Correct Answers.
A 6 year old girl with severe birth defects who is mentally disabled is brought to the emergency
room because of a broken arm. The caregiver reports that the girl sustained the injury when she
fell from her wheelchair. Which intervention is most important for the nurse to implement? -
Answer Evaluate the child for other injuries. Rationale: Because a 6-year-old child with low
level fall that results in a fracture should be considered a possible victim of child abuse, until
proven otherwise.
The community health nurse facilitates a substance abuse prevention group for a homeless
population. Which statement demonstrates that a client has a realistic understanding of the
recovery process? - Answer "By learning what led to my latest relapse, I know what to do in
the future." Rationale: Recovery is a lifelong process in which clients must constantly learn and
apply new behaviors to replace ineffective ones. Every attempt toward recovery improves long-
term chances of success, so those who learn from their relapses demonstrate an understanding
of the process.
A woman admitted to the Emergency Department is bleeding profusely from a patch where her
hair was lost from her scalp. She is accompanies by her husband who tells the nurse that his
wife caught her hair on the railing and pulled it out when she fell down the stairs. The husband
is solicitous of his wife and quickly answers questions on her behalf. He attempts to comfort his
wife by saying to her, "I am right here with you, dear. Nothing can keep us apart." What is the
priority nursing intervention? - Answer Require the husband to leave the cubicle while the
client is being treated. Rationale: This client should be questioned about the possibility of
spousal abuse and cannot answer truthfully in the presence of the perpetrator, so separating
the couple is a priority.
While assessing a 70-year old male client, a nurse working in the outpatient clinic notices
bruises on the client's chest. The client admits that his daughter, who is his caregiver, becomes
frustrated and sometimes hits him. What is the priority outcome for the elderly client who
sustained the abuse? - Answer Expresses his feelings of satisfaction with care. Rationale:
Abuse cessation should result in the client feeling satisfied with his care.
The nurse is assessing a client who is believed to have a borderline personality disorder. Which
question is most important to include in this assessment? - Answer "Do you frequently have
temper tantrums?" Rationale: Those with a borderline personality disorder demonstrate intense
outbursts of anger.
A nurse is teaching a female client who is in a homosexual relationship about women's health.
Which topic is the most important for the nurse to address? - Answer Domestic violence
interventions. Rationale: Since all women, regardless of sexual orientation, are at risk for
domestic violence that can be potentially lethal, this is the most important topic for the nurse to
address.