141. Key: C                                                      

Client Need: Psychosocial Adaptation

C. Statements made by a patient that focus on God. prayer. faith. church or religious topics are used to assess for spiritual distress. The nursing diagnosis of spiritual distress is the state in which the individual experiences or is at risk for experiencing a disturbance in the belief or value system that provides strength, hope and meaning to life.

A. This statement does not relate to spiritual distress in the adult survivor of childhood sexual abuse. It reflects the individual's feelings of powerlessness that are commonly experienced by the adult survivor of abuse.

B. This statement reflects the individual's feelings of guilt associated with the sexual abuse. This would support a diagnosis of self-esteem disturbance.

D. Praying for the person is often healing in nature and does not indicate disturbance in one's belief system.

142. Key：C                                                   

Client Need, Growth and Development

C. A positive Babinski reflex is a normal finding in a newborn. It does disappear by the first year of life. If. on examination. the Babinski reflex is absent, It is significant and should be followed up with a neurology consult.

A. A stepping reflex is expected in a newborn up to three to four weeks of age.

B. An asymmetrical Moro reflex is indicative of muscle or nerve damage during the delivery. All reflexes should be symmetrical.

D. Unilateral grasp reflex may be indicative of a fractured clavicle or damage to the brachial plexussustained during delivery.

 143. Key：D                                                       

Client Need: Psychosocial Adaptation

D. Psychiatric patients need to be checked after administering oral medications to ensure that they have swallowed pills and not "checked" them. Patients can retain a pill under the tongue or in the cavity of the cheek; therefore. it is important that the nurse inspect the patient's mouth after each dose of medication.

A. Administration of a medication via the intramuscular route will ensure that the patient has received it. However. it is not the preferred route of administration. because it often produces pain and anxiety in the patient. Many psychiatric medications are manufactured only in pill or liquid form.

B. A patient can appear to have swallowed a pill, while holding it under the tongue or in the cheek cavity. Signs of swallowing do not ensure that the medication has in fact been ingested.

C. Engaging the patient in conversation for five minutes after she takes medication does not ensure that the patient has swallowed a pill.

144. Key：A                                                     

Client Need, Growth and Development

A. According to the Denver Developmental Screening Test II-Revised (DDST-R) 50% of children combine syllables by the age of nine months and 90% do so by the age of 10 months. Almost all children combine words by the age of 24 months. A 36-month-old child who does not link syllables together is exhibiting an alteration in normal growth and development.

B. The child may be using pointing as a method of communicating his/her desires or needs in order to compensate for the discrepancy that often exists between the receptive language (understanding the spoken word) and expressive language (speaking in words). Also, toddlers are often shy around strangers and may use hand gestures.

C. Receptive speech surpasses expressive speech for the majority of early school years. For this reason. stuttering is considered normal until five or six years of age. Stuttering occurs when expressive speech cannot keep pace with the child's thoughts and intentions to speak.

D. Repeating words and hesitating while speaking are characteristic of a 36-month-old's speech patterns.

145. Key:C                                    

Client Need, Pharmacological and Parenteral Therapies

C. There are two major classifications for P1CC line occlusions, thrombotic or non-thrombotic. A non-thrombotic occlusion may be caused by a kinked or clamped catheter; an obstruction of the In-line filter; pinch-off syndrome, catheter rupture, catheter malposition or migration; or drug and mineral precipitates or lipid residue. The first step in trouble-shooting an occlusion is to assess the situation.Therefore. examining the line for kinks would be the next step.

A. After assessing the problem, the nurse should contact the primary physician on call. Anything other than releasing a kink or unclamping the line and replacing a clogged in-line filter would require a physician's order.

B. Attempting to flush a line after meeting resistance could cause life-threatening dislodgement of a thrombus and should never be done.

D. If a line will not flush. waiting until the next dose is due will almost assuredly create a larger obstruction, necessitating the possible removal and reinsertion of a new line. It is unacceptable to hold a medication without a physician's order to do so.