STUDY GUIDE COMPLETE RESPONSES
◉ The nurse is working with victims of domestic abuse. The nurse
should understand which of these factors is a reason why domestic
violence or emotional abuse remains extensively undetected?
A. The expenses due to police and court costs are prohibitive
B. Little knowledge is known about batterers and battering
relationships
C. There are typically many series of minor, vague complaints
D. Few people who have been battered seek medical care. Answer: C
Signs of domestic violence or emotional abuse may not be clearly
manifested and include many series of a minor complaints such as
headache, abdominal pain, insomnia, back pain and dizziness. These
may be covert indications of violence or abuse that go undetected.
These complaints may be vague and reflect ambivalence about the
disclosure of any violence or abuse.
◉ The nurse is obtaining an aerobic wound culture from a client
with stage two pressure injury. The nurse first removes a gauze
dressing and observes a moderate amount of purulent drainage on
the dressing and then the nurse performs hand hygiene. What is the
next correct step in the procedure?
,A. Swab the gauze dressing that was removed from the wound
B. Irrigate the wound with normal saline
C. Obtain a culture by rotating a sterile swab in the open wound
D. Remove wound exudate from the wound edges with a cotton tip
applicator Answer: B
After removing the dressing and performing hand hygiene, the
wound needs to be irrigated to remove surface pathogens before the
nurse can obtain a wound culture. Cultures are not obtained from
wound exudate on the dressing or wounds that have not been
irrigated since the exudate may be contaminated with normal skin
flora.
◉ The nurse is caring for a client who is experiencing frightening
hallucinations that are markedly increased at night. The client's
partner asks to stay a few hours beyond the visiting time, in the
client's private room. What would be the best response by the
nurse?
A. "Yes, staying with the client and orienting the client to the
surroundings may decrease any anxiety."
B. "No, your presence may cause the client to become more anxious."
C. "No, it would be best if you brought the client some reading
material that the client could read at night."
,D. "Yes, would you like to spend the night when the client's behavior
indicates that the client is or will be frightened?" Answer: A
Encouragement of a family member or a close friend to stay with the
client in a quiet surrounding cannot only help increase orientation,
but can also minimize confusion and anxiety. The visitor could also
report to the nurse any unusual findings of the client. This would be
the most supportive approach for this client.
◉ The RN, who is functioning as the charge nurse, needs to
determine shift assignments. How will the charge nurse determine
which client assignments are appropriate for the licensed practical
nurse (LPN)?
A. Ask the LPN about prior experience caring for clients with similar
diagnoses
B. Determine how many nursing assistants are available to help the
LPN with client care
C. Refer to the list of technical tasks LPNs are trained to perform
D. Review the procedure manual with the LPN prior to making an
assignment Answer: A
The definition of assignment is the routine care, activities and
procedures that are within the authorized scope of practice of the
RN or LPN/LVN. The RN must determine the needs of the clients and
make assignments not only based on scope of practice, but also
education, demonstrated competency and skill level. Regardless if
the LPN received education and training to perform specific skills,
, the RN needs to determine the LPN's experience with caring for
clients with similar diagnoses. While the RN is responsible for
ensuring an assignment given to a delegatee is carried out
completely and correctly, the LPN must be able to perform the skills
or tasks independently.
◉ The nurse is caring for a school-aged child with a diagnosis of
secondary hyperparathyroidism after treatment for chronic renal
disease. Which serum lab data should receive priority attention by
the nurse?
A. Osmolality and sodium
B. Blood urea nitrogen and magnesium
C. Calcium and phosphorus
D. Glucose and potassium Answer: C
The parathyroid regulates the calcium and phosphorus serum levels.
Calcium and phosphorous levels will be elevated in hyperfunction of
this gland until the client is stabilized. To recall this information
think of a see-saw. Associate that calcium is first in the alphabet and
thus calcium follows the direction of the abnormality - hyper or
hypo function - of the parathyroid. Put the calcium on one side and
the phosphorus on the other side of the see-saw.
◉ The nurse is caring for a client who just had a central venous
catheter line inserted at the bedside. Which of these assessments
requires immediate attention by the nurse?