Nokea
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
- A. Blood pressure 144/82 mm Hg
- B. Urine specific gravity 1.03
- C. Neck vein distention
- D. Urine specific gravity 1.01
Correct Answer: A
Rationale: The correct answer is A. The elevated blood pressure of 144/82 mm Hg indicates dehydration due to vomiting and diarrhea, leading to hypovolemia. This is a compensatory mechanism by the body to maintain perfusion. Option B, urine specific gravity of 1.03, indicates concentrated urine and dehydration, but not as specific as elevated blood pressure. Option C, neck vein distention, is more indicative of heart failure or fluid overload rather than dehydration. Option D, urine specific gravity of 1.01, indicates diluted urine and is not consistent with dehydration. Therefore, based on the symptoms and the compensatory mechanism of the body, an elevated blood pressure is the most likely finding in a client with vomiting and diarrhea.
You may also like to solve these questions
Which of the following is an example of a sentinel event?
- A. A patient fall with no injury
- B. A medication error that results in no harm
- C. A patient suicide while in a healthcare facility
- D. A near miss incident
Correct Answer: C
Rationale: The correct answer is C because a sentinel event is a serious, unexpected occurrence in a healthcare setting that results in death or serious physical or psychological harm to a patient. A patient suicide while in a healthcare facility meets this criteria. A is incorrect as a fall with no injury is not a sentinel event. B is incorrect as a medication error resulting in no harm is not a sentinel event. D is incorrect as a near miss incident, although serious, does not result in harm to the patient.
Which of the following best describes the concept of evidence-based management?
- A. Using personal experience to make managerial decisions
- B. Combining managerial expertise with the latest research evidence
- C. Using intuition and experience to guide management decisions
- D. Relying on peer-reviewed literature to inform management practices
Correct Answer: B
Rationale: The correct answer is B because evidence-based management involves integrating managerial expertise with research evidence to make informed decisions. This approach ensures decisions are grounded in data and proven strategies, leading to more effective outcomes. Choice A is incorrect as it relies solely on personal experience, neglecting valuable external evidence. Choice C is incorrect as intuition alone may not always lead to optimal decisions. Choice D is incorrect as it focuses only on peer-reviewed literature, excluding the importance of combining it with managerial expertise.
An RN knows that sometimes, when working through an ethical dilemma, the decision makers are unable to arrive at a mutually agreed upon decision. Which of the following is a reason why an agreement cannot be reached?
- A. One or more of the parties may be able to reconcile their values.
- B. The patient’s point of view is recognized as valuable.
- C. The dilemma involves two or more equally unpleasant choices.
- D. The institution is unable to honor the patient’s request.
Correct Answer: C
Rationale: The correct answer is C because when an ethical dilemma involves two or more equally unpleasant choices, it can be challenging for decision-makers to come to a consensus. This is known as a moral dilemma, where there is no clear right or wrong option, making it difficult to reach an agreement. In such cases, individuals may have strong convictions about different courses of action, leading to a deadlock in decision-making.
Incorrect choices:
A: One or more of the parties may be able to reconcile their values - This choice suggests that parties can find common ground by adjusting their values, which is not always possible in complex ethical dilemmas.
B: The patient’s point of view is recognized as valuable - While recognizing the patient's perspective is important, it may not directly address the core reason why an agreement cannot be reached.
D: The institution is unable to honor the patient’s request - This choice focuses on institutional constraints rather than the fundamental nature of ethical dilemmas and decision-making processes.
Which of the following is an example of a secondary prevention strategy?
- A. Administering flu vaccinations
- B. Screening for hypertension
- C. Performing a mastectomy
- D. Providing rehabilitation after surgery
Correct Answer: B
Rationale: The correct answer is B: Screening for hypertension. Secondary prevention aims to detect and treat a disease in its early stages to prevent further progression. Screening for hypertension helps identify individuals at risk and enables timely intervention to prevent complications. Administering flu vaccinations (A) is an example of primary prevention. Performing a mastectomy (C) is a treatment method for existing breast cancer, falling under tertiary prevention. Providing rehabilitation after surgery (D) focuses on restoring function post-treatment, also part of tertiary prevention.
Your nurse manager talks with you once per week to determine how you are adjusting to your role as a new nurse. She asks if you feel that you are able to provide good care to your patients, whether you are becoming familiar with the electronic health record, and whether your preceptor is encouraging your independence. This manager is demonstrating:
- A. An intrusive style.
- B. An effort to understand if you are coping with the demands.
- C. An attempt to intimidate.
- D. An authoritarian style.
Correct Answer: B
Rationale: The correct answer is B because the nurse manager is showing genuine concern for the new nurse's well-being and professional development. By asking about the nurse's ability to provide care, familiarity with the EHR, and support from the preceptor, the manager is seeking to understand and support the nurse's adjustment to the new role. This approach fosters open communication and a supportive environment.
Incorrect Choices:
A: An intrusive style implies invading personal boundaries, which is not evident in the scenario.
C: Intimidation involves creating fear or anxiety, which is not reflected in the manager's behavior.
D: An authoritarian style is characterized by strict control and limited feedback, which contradicts the manager's supportive and open approach.