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A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client's body temperature?
- A. Oral
- B. Axillary
- C. Arterial line
- D. Rectal
Correct Answer: B
Rationale: Axillary avoids the oral route post-surgery and is appropriate for a flushed, warm client.
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Which of the following statement best describe disability?
- A. Temporary loss of function
- B. Permanent loss of function
- C. Absence of disease
- D. A state of well being
Correct Answer: B
Rationale: Disability is permanent loss of function (B), per definition e.g., amputation impact. Temporary (A) is impairment, absence (C) health, well-being (D) opposite. B best defines disability's chronicity, making it correct.
Which actions are examples of an RN participating in illness prevention for a client with hypertension?
- A. Teaching lifestyle modifications
- B. Reporting low blood pressure to the health care provider
- C. Administering ordered medication
- D. Performing risk screenings for hypertension
Correct Answer: A
Rationale: Illness prevention in nursing focuses on proactive measures to stop disease development, particularly for conditions like hypertension. Teaching lifestyle modifications, such as diet and exercise, empowers clients to manage blood pressure and reduce risk, aligning with primary prevention's educational emphasis. Performing risk screenings identifies hypertension early, enabling timely intervention before complications arise, another primary prevention strategy. Providing heart-healthy diet literature reinforces these efforts, equipping clients with practical tools for prevention. Reporting low blood pressure or administering medications, while critical interventions, address existing conditions rather than prevent onset, falling under treatment or management. Nurses' preventive role leverages education and screening to foster healthy habits and early detection, significantly impacting chronic disease trajectories like hypertension, where lifestyle plays a pivotal role.
The goal of nursing is to put the patient in the best condition for nature to act upon him'. This was stated by
- A. Henderson
- B. Jean Watson
- C. Marta Rogers
- D. Florence Nightingale
Correct Answer: D
Rationale: This quote reflects a historical view of nursing as facilitating natural healing, attributed to Florence Nightingale, the founder of modern nursing. In her 1859 work, *Notes on Nursing*, she emphasized optimizing the patient's environment cleanliness, air, and rest for recovery. Henderson defined nursing through 14 basic needs, Watson focused on caring theory, and Rogers developed a science of unitary beings none match this phrasing. Nightingale's philosophy shaped nursing's focus on holistic care, influencing practice for centuries by prioritizing patient conditions over direct intervention.
Considered as the most accessible and convenient method for temperature taking
- A. Oral
- B. Rectal
- C. Tympanic
- D. Axillary
Correct Answer: A
Rationale: Oral temperature is most accessible e.g., quick placement under tongue requiring minimal prep, unlike rectal (invasive), tympanic (equipment), or axillary (longer). Convenient for alert patients, it's standard in clinics, per nursing practice, balancing ease and reliability for routine monitoring.
A client has a mean arterial blood pressure (MAP) of $97 \mathrm{mmHg}$ and an intracranial pressure (ICP) of $12 \mathrm{mmHg}$. What is the cerebral perfusion pressure (CPP) for this client?
- A. 75
- B. 85
- C. 97
- D. 109
Correct Answer: B
Rationale: CPP = MAP - ICP; 97 - 12 = 85 mmHg (B). Other options (A, C, D) miscalculate. B is correct. Rationale: CPP measures brain perfusion; 85 mmHg is within normal (60-100 mmHg), critical for assessing adequacy post-injury, per neurocritical care formulas.