Nokea
What is the correct sequence for assessing the abdomen?
- A. Tympanic percussion, measurement of abdominal girth, and inspection
- B. Assessment for distention, tenderness, and discoloration around the umbilicus
- C. Percussion, palpation, and auscultation
- D. Auscultation, percussion, and palpation
Correct Answer: D
Rationale: The correct sequence for assessing the abdomen is auscultation, percussion, and palpation. Auscultation allows the healthcare provider to listen for bowel sounds, followed by percussion to assess for areas of tenderness or abnormal distention, and finally palpation to feel for masses or organ enlargement. This sequence ensures a systematic and thorough assessment of the abdomen.
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If a healthcare provider administers an injection to a patient who refuses, they have committed:
- A. Assault and battery
- B. Negligence
- C. Malpractice
- D. None of the above
Correct Answer: A
Rationale: When a healthcare provider administers treatment, such as an injection, against a patient's refusal or will, it constitutes assault and battery. Assault refers to the intentional act that causes a person to fear that they will be touched without consent, while battery involves the actual harmful or offensive contact. In this scenario, administering the injection without the patient's consent is both an assault (causing fear of unwanted contact) and a battery (unwanted physical contact). Therefore, the correct answer is 'Assault and battery.' Negligence refers to a failure to exercise the appropriate level of care expected in a situation, while malpractice involves professional negligence or misconduct.
A patient presents with an exacerbation of chronic obstructive pulmonary disease (COPD) characterized by shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough. An appropriate nursing diagnosis would be:
- A. Ineffective airway clearance related to thick, tenacious secretions.
- B. Ineffective airway clearance related to dry, hacking cough.
- C. Ineffective individual coping with COPD.
- D. Pain related to immobilization of affected leg.
Correct Answer: A
Rationale: The patient's symptoms of shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough all point towards a potential airway clearance issue. This makes option A, 'Ineffective airway clearance related to thick, tenacious secretions,' the most appropriate nursing diagnosis. It directly addresses the thick secretions and suggests a potential cause of the breathing difficulty the patient is experiencing.
For abdominal inspection, in which of the following positions should a patient be placed?
- A. Prone
- B. Trendelenburg
- C. Supine
- D. Side-lying
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse?
- A. Administer oxygen by Venturi mask at 24% as needed
- B. Allow a 1-hour rest period between activities
- C. Patients and nurses both respond well to primary nursing care units
- D. Studies have shown that patients and nurses both respond well to primary nursing care units
Correct Answer: C
Rationale: Primary nursing care units have been proven to be highly satisfying for both patients and nurses. This model promotes a consistent and continuous relationship between a patient and a primary nurse, leading to improved communication, personalized care, and overall satisfaction for both parties involved.
Which of the following measures is not recommended to prevent pressure ulcers?
- A. Massaging the reddened area with lotion
- B. Using a water or air mattress
- C. Adhering to a schedule for positioning and turning
- D. Providing meticulous skin care
Correct Answer: A
Rationale: Massaging a reddened area can cause further tissue damage by increasing pressure on already compromised skin. The other options, such as using specialized mattresses, adhering to repositioning schedules, and maintaining good skin care, are all recommended strategies to prevent pressure ulcers by reducing pressure and friction on vulnerable areas of the skin.