Nokea
During which step of the nursing process does the nurse analyze data related to the patient's health status?
- A. Assessment
- B. Implementation
- C. Diagnosis
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is 'Assessment.' During the assessment phase of the nursing process, the nurse collects and analyzes data related to the patient's health status. This involves gathering information through various means such as patient interviews, physical examinations, and reviewing medical records. Choice B, 'Implementation,' refers to the phase where the nurse carries out the planned interventions. Choices C and D, 'Diagnosis' and 'Evaluation,' come after the assessment phase in the nursing process.
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In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?
- A. Instruct the client to observe strict bed rest
- B. Check for epidural catheter drainage
- C. Administer analgesia through the epidural catheter as prescribed
- D. Assess respiratory rate carefully
Correct Answer: D
Rationale: The nursing priority care in a case where an epidural catheter for Fentanyl epidural analgesia is given during hip surgeries is to assess the respiratory rate carefully. Respiratory depression is a potential side effect of Fentanyl, especially when administered epidurally. Monitoring the respiratory rate is crucial to detect any signs of respiratory distress promptly. Instructing the client to observe strict bed rest (Choice A) may be necessary but is not the priority over ensuring respiratory function. Checking for epidural catheter drainage (Choice B) and administering analgesia through the epidural catheter as prescribed (Choice C) are important aspects of care, but ensuring adequate ventilation takes precedence to prevent complications.
A patient is on a low-sodium diet. Which food item should the patient avoid?
- A. Fresh fruit
- B. Canned soup
- C. Whole grain bread
- D. Grilled chicken
Correct Answer: B
Rationale: The correct answer is B: Canned soup. Canned soup is commonly high in sodium content, which is not suitable for a patient on a low-sodium diet. Fresh fruit, whole grain bread, and grilled chicken typically have lower sodium levels and can be included in a low-sodium diet. Therefore, the patient should avoid canned soup to adhere to the requirements of a low-sodium diet.
What is the purpose of the cuff in a Tracheostomy tube?
- A. Separate the upper and lower airway
- B. Separate trachea from the esophagus
- C. Separate the larynx from the nasopharynx
- D. Secure the placement of the tube
Correct Answer: B
Rationale: The purpose of the cuff in a Tracheostomy tube is to separate the trachea from the esophagus. The cuff helps prevent aspiration by creating a seal that separates the trachea from the esophagus, reducing the risk of food or fluids entering the lungs. Choices A, C, and D are incorrect because the cuff's primary function in a Tracheostomy tube is to prevent aspiration rather than separating the upper and lower airway, larynx from the nasopharynx, or securing the placement of the tube.
Which of the following is a form of primary prevention?
- A. Regular Check-ups
- B. Regular Screening
- C. Self-Medication
- D. Immunization
Correct Answer: D
Rationale: The correct answer is D, 'Immunization.' Primary prevention aims to prevent disease before it occurs by preventing exposure to risk factors. Immunization is a classic example of primary prevention as it helps prevent the development of infectious diseases. Choice A, 'Regular Check-ups,' is more related to secondary prevention by detecting diseases early. Choice B, 'Regular Screening,' is also more aligned with secondary prevention as it involves early detection of diseases. Choice C, 'Self-Medication,' is not a form of primary prevention but rather a risky practice that can lead to adverse outcomes.
Toilet training occurs in the anal stage of Freud's psychosexual development. This is equivalent to Erikson's:
- A. Trust vs. Mistrust
- B. Autonomy vs. Shame and Doubt
- C. Initiative vs. Guilt
- D. Industry vs. Inferiority
Correct Answer: A
Rationale: The correct answer is A: Trust vs. Mistrust. In Freud's psychosexual development theory, the anal stage is where toilet training occurs, focusing on issues of control and independence. This stage is parallel to Erikson's Trust vs. Mistrust stage, where infants learn to trust or mistrust their caregivers based on the consistency of care they receive. Choices B, C, and D are incorrect as they correspond to different stages in Erikson's psychosocial development theory, not related to toilet training or the anal stage of Freud's theory.