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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.
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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.
The nurse is caring for a client with a closed reduction of the left forearm. Which finding should be reported to the physician immediately?
- A. The client complains of pain at the site of the fracture
- B. The client's fingers are cool and pale
- C. The client's cast has a foul odor
- D. The client's radial pulse is 88 beats per minute
Correct Answer: B
Rationale: Cool, pale fingers post-left forearm closed reduction indicate circulatory compromise, possibly compartment syndrome, needing urgent reporting pain is expected, odor suggests infection (less acute), and pulse (88) is normal. Nurses assess neurovascular status, acting fast, preventing tissue damage in this orthopedic emergency.
The most important nursing intervention to correct skin dryness is:
- A. Avoid bathing the patient until the condition is remedied, and notify the physician
- B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear
- C. Consult the dietitian about increasing the patient's fat intake, and take necessary measures to prevent infection
- D. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas
Correct Answer: D
Rationale: Hydration, gentle soap, and lotion address dryness and prevent cracking.
Which assessment finding indicates a potential musculoskeletal complication of immobility?
- A. Increased muscle tone
- B. Active range of motion (ROM)
- C. Contractures
- D. Strong and flexible joints
Correct Answer: C
Rationale: Contractures permanent muscle and tendon shortening indicate a musculoskeletal complication of immobility, restricting joint movement due to prolonged stillness. High muscle tone might suggest other conditions, while active motion and strong joints reflect health, not issues. Nurses assess for this to initiate stretching or therapy, countering the stiffening that immobility causes, ensuring musculoskeletal function is preserved as much as possible in affected patients.
They put girls clothes on male infants to drive evil forces away
- A. Chinese
- B. Egyptian
- C. Indian
- D. Babylonian
Correct Answer: A
Rationale: Ancient Chinese dressed male infants in girls' clothes to confuse demons e.g., during infancy rites believing males drew evil. Unlike Egyptian, Indian, or Babylonian customs, this reflects spiritual protection, offering insight into cultural health beliefs relevant to nursing's cultural competence.