Nokea
A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?
- A. Decreased appetite
- B. A low-grade fever
- C. Chest congestion
- D. Constant swallowing
Correct Answer: D
Rationale: A complication of a tonsillectomy is bleeding, and constant swallowing may indicate bleeding. Decreased appetite is expected after a tonsillectomy, as is a low-grade fever; thus, answers A and B are incorrect. Chest congestion, as mentioned in answer C, is not typical of tonsillectomy complications, making it an incorrect choice.
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Which of the following attitudes is essential in a nurse who assists clients during crises?
- A. viewing crisis intervention as the first step in solving bigger problems
- B. wanting to help clients solve all problems identified
- C. taking an active role in guiding the process
- D. feeling that work requires identification with all of a client's problems
Correct Answer: A
Rationale: Viewing crisis intervention as the first step in solving bigger problems is essential in a nurse who assists clients during crises. This approach focuses on addressing the immediate crisis first, which can potentially prevent the escalation of bigger problems. Wanting to help clients solve all problems identified (Choice B) may not be feasible or necessary during a crisis situation where immediate intervention is crucial. Taking an active role in guiding the process (Choice C) is important, but the primary focus should be on crisis intervention. Feeling that work requires identification with all of a client's problems (Choice D) may lead to a lack of focus on the immediate crisis at hand.
Which of the following statements by a client with spinal cord injury indicates a need for further teaching by the nurse regarding bowel management?
- A. "I should avoid eating foods that produce gas."?
- B. "I should drink more fluids like water and non-caffeinated fruit juices."?
- C. "I should set a regular schedule for bowel movements."?
- D. "I should sit in an upright position for bowel movements."?
Correct Answer: B
Rationale: The corrected statement indicates the need for further teaching because it suggests consuming fluids like fruit juices, which can include caffeinated options that may stimulate fluid loss through increased urination. It is more appropriate to emphasize the consumption of fluids like water and non-caffeinated fruit juices for proper hydration. Choices A, C, and D demonstrate a correct understanding of bowel management by focusing on dietary considerations, establishing a regular bowel movement schedule, and using proper positioning during bowel movements. Option B is incorrect as it may lead to increased fluid loss due to caffeine content in some fruit juices.
As a type of quality indicator, an example of a structure standard is:
- A. a written philosophy.
- B. a procedure for a straight catheterization.
- C. a protocol for treatment of a client with chest pain.
- D. the diagnostic work-up for a client with abdominal pain.
Correct Answer: A
Rationale: The correct answer is 'a written philosophy.' Structure standards define the conditions needed to operate a system and do not directly involve client care. Examples include philosophy, objectives, goals, hours of operation, and management responsibility. Choices B, C, and D involve specific procedures and protocols related to client care, which are not structure standards.
The client is taking prednisone 7.5mg po each morning to treat his systemic lupus erythematosus. Which statement best explains the reason for taking the prednisone in the morning?
- A. There is less chance of forgetting the medication if taken in the morning.
- B. There will be less fluid retention if taken in the morning.
- C. Prednisone is absorbed best with the breakfast meal.
- D. Morning administration mimics the body's natural secretion of corticosteroid.
Correct Answer: D
Rationale: Taking corticosteroids in the morning mimics the body's natural release of cortisol, which follows a diurnal pattern with higher levels in the morning. This timing helps regulate the body's inflammatory response and minimizes potential side effects. Answer A is not the primary reason for morning dosing, as adherence concerns can be addressed through other means. Answer B is incorrect since fluid retention is not influenced by the timing of prednisone administration. Answer C is also incorrect as prednisone absorption is not significantly affected by whether it is taken with breakfast or not.
The nurse is caring for a dying client who has persistently requested that the nurse 'help her to die and be in peace.' According to the Code of Ethics for Nurses, the nurse should:
- A. Ask the client whether she has signed the advance directives document.
- B. Tell the client that he or she will ask another nurse to care for her.
- C. Instruct the client that only a physician can legally assist in suicide.
- D. Try to make the client as comfortable as possible, but refuse to assist in death.
Correct Answer: D
Rationale: The correct answer is to try to make the client as comfortable as possible but refuse to assist in death. According to the Code of Ethics for Nurses, nurses are committed to providing compassionate care, respecting the dignity and rights of the dying person. In this situation, it is important for the nurse to focus on providing comfort and support to the client while upholding ethical standards. Choice A is incorrect because discussing advance directives does not address the immediate request for assistance in dying. Choice B is incorrect as it does not address the ethical dilemma presented. Choice C is incorrect because instructing the client that only a physician can assist in suicide does not fully address the complexity of the situation or the nurse's role in providing end-of-life care.