1.
What needs of a patient does a nurse address?
Correct Answer
D. All of the above
Explanation
Nurses address a patient's physical needs through medical care, administer emotional support to alleviate stress, and attend to mental well-being by considering cognitive aspects. Their holistic approach ensures comprehensive care, fostering overall health and recovery for individuals under their supervision.
2.
A client has developed thrombophlebitis of the left leg. What is the most important nursing intervention to prioritize?
Correct Answer
A. Elevate leg on 2 pillows.
Explanation
Elevating the leg on two pillows is a nursing intervention commonly used to manage thrombophlebitis. By elevating the leg, the goal is to reduce swelling and enhance venous return, helping to alleviate symptoms and promote healing. This position aids in preventing stasis of blood in the affected leg and may contribute to overall comfort.
3.
What is the normal body temperature in Celsius?
Correct Answer
A. 36.5–37.5
Explanation
The normal body temperature in Celsius is 36.5–37.5. It represents the healthy range for most individuals. Maintaining a stable body temperature is crucial for overall health and proper bodily functions. Fluctuations outside of this range may indicate an underlying health issue that should be addressed by a medical professional. It is important to monitor changes in body temperature and seek medical attention if there are any concerns. Additionally, staying hydrated and dressing appropriately for the weather can help regulate body temperature.
4.
Which of these is an example of a variation in the newborn resulting from the presence of maternal hormones?
Correct Answer
A. Engorgement of the breasts.
Explanation
Engorgement of the breasts is an example of a variation in the newborn resulting from the presence of maternal hormones. During pregnancy, maternal hormones stimulate the development of the mammary glands in the fetus. After birth, the sudden withdrawal of these hormones can lead to breast engorgement in both male and female infants. This is a temporary and normal variation that typically resolves on its own as the infant's body adjusts to the postnatal environment.
5.
The nursing care plan for a client with decreased adrenal function should include
Correct Answer
D. Measures to prevent constipation.
Explanation
For a client with decreased adrenal function, such as in Addison's disease or secondary adrenal insufficiency, the nursing care plan should include measures to prevent constipation. Decreased adrenal function can lead to gastrointestinal symptoms, including a sluggish bowel due to reduced cortisol levels, which can necessitate measures to promote regular bowel movements.
6.
Which method is commonly used to measure blood pressure?
Correct Answer
A. SpHygmomanometer
Explanation
A sphygmomanometer is commonly used to measure blood pressure, ensuring accurate systolic and diastolic readings. This device consists of an inflatable cuff that is placed around the upper arm, a pressure gauge to measure the pressure within the cuff, and a stethoscope to listen for the sound of blood flow. The results obtained from a sphygmomanometer are crucial in diagnosing and managing hypertension.
7.
While
assessing a client in an outpatient facility with a panic disorder, the nurse
completes a thorough health history and physical exam. Which finding is most significant for this client?
Correct Answer
B. Sense of impending doom.
Explanation
A sense of impending doom is a common and characteristic symptom of panic attacks in individuals with panic disorder. It is often described as an overwhelming feeling of fear, apprehension, or impending catastrophe. This symptom distinguishes panic disorder from other anxiety disorders. Compulsive behavior, fear of flying, and predictable episodes may be associated with other anxiety disorders but are not as specific to panic disorder.
8.
The nurse
is reviewing a depressed client's history from an earlier admission.
Documentation of anhedonia is noted. The nurse understands that this finding
refers to:
Correct Answer
C. Lack of enjoyment in usual pleasures.
Explanation
Anhedonia is a key symptom of depression and is characterized by a diminished ability to experience pleasure or interest in activities that were previously enjoyable. It can affect various aspects of life, including hobbies, social interactions, and other activities that used to bring joy. The other options, such as difficulty sleeping, persistent suicidal thoughts, and reduced senses of taste and smell, are associated with depression but do not specifically represent anhedonia.
9.
The nurse
is caring for a client in the coronary care unit. The display on the cardiac
monitor indicates ventricular fibrillation. What ought to be done first by the nurse?
Correct Answer
C. Assess for the presence of pulse.
Explanation
The correct answer is C: Assess for presence of pulse
Artifact can mimic ventricular fibrillation on a cardiac monitor. If the client is truly in ventricular fibrillation, no pulse will be present. The standard of care is to verify the monitor display with an assessment of the client’s pulse.
10.
A nurse evaluating a special needs 2-year-old in a clinic should stress which goal when talking to the child's mother?
Correct Answer
C. Promoting the child's optimal development
Explanation
Promoting optimal development is a key focus in the care of special needs children. This involves addressing the child's individual needs, milestones, and abilities, and providing interventions and support to maximize their overall development. While aspects of self-care skills and toileting may be part of the child's development plan, the overarching goal is to ensure the child reaches their highest potential in all aspects of growth and development.
11.
Which route is used for the fastest drug absorption?
Correct Answer
A. Intravenous
Explanation
The intravenous route is used for the fastest drug absorption as it delivers medication directly into the bloodstream. This method is often preferred in emergency situations when immediate effects are needed. Additionally, intravenous administration allows for precise control over the dosage of medication given to the patient. It is also commonly used for patients who are unable to take medications orally. Intravenous administration bypasses the digestive system, ensuring that the full dose of medication reaches the bloodstream quickly and efficiently.
12.
What is the best way to ensure patient identification before medication administration?
Correct Answer
A. Checking the patient’s ID band
Explanation
Checking the patient’s ID band is the best way to ensure proper identification before administering medication. This step helps prevent medication errors and ensures that the right patient receives the right treatment. It is important to verify the patient's identity using at least two unique identifiers before proceeding with any medical interventions.
13.
An HIV/AIDS-positive new mother is the nurse's patient. The student questions the nurse about the methods other than a positive HIV test that are used to diagnose AIDS. The nurse answers:
Correct Answer
C. "CD4 lympHocyte count is less than 200."
Explanation
The correct answer is C: "CD4 lymphocyte count is less than 200." CD4 lymphocyte counts are normally 600 to 1000. In 1993 the Center for Disease Control defined AIDS as having a positive HIV plus one of these – the presence of an opportunistic infection or a CD4 lymphocyte count of less than 200.
14.
Which position is ideal for a patient in respiratory distress?
Correct Answer
A. Fowler’s
Explanation
Fowler’s position is ideal for a patient in respiratory distress as it promotes better lung expansion. This position involves the patient sitting upright at a 45-60 degree angle, which helps to improve oxygenation and ease breathing. It is commonly used in emergency situations such as asthma attacks or heart failure exacerbations. In addition to improving oxygenation and ease of breathing, Fowler's position also helps reduce the risk of aspiration. This position is also beneficial for patients experiencing chest pain or difficulty swallowing.
15.
The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions?
Correct Answer
B. Increasing oral fluid intake to 3000 cc per day
Explanation
Increasing oral fluid intake to 3000 cc per day is a reasonable and supportive intervention for a client with pneumococcal pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to mobilize and clear. While chest physiotherapy is a more direct method for removing secretions, promoting hydration is a valuable complementary measure. It is essential to consider a holistic approach to care, combining strategies that support both hydration and respiratory clearance for optimal outcomes in pneumonia management.