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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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After a month, Mr. Gary's wife started going to her old routine, She said 'Gary would want me to continue living my life' This is an example of what stage of grieving?
- A. Denial
- B. Anger
- C. Bargaining
- D. Acceptance
Correct Answer: D
Rationale: Resuming routine with 'Gary would want is acceptance (D), per Kubler-Ross peace with loss, moving forward. Denial (A), anger (B), and bargaining (C) resist or alter reality. Acceptance reflects her adjustment, making it correct.
A client who recently underwent a coronary artery bypass graft is taking furosemide and metoprolol following the procedure. While developing a plan for a heart-healthy diet with the nurse, the client states that diet did not contribute to the heart disease and that the client should be fine just continuing to take the medications. According to the Stages of Change Model, which stage of change is the client in related to diet?
- A. Precontemplation
- B. Contemplation
- C. Preparation
- D. Maintenance
Correct Answer: A
Rationale: The Stages of Change Model tracks behavior shift, and this client's denial of diet's role in heart disease places them in precontemplation. Here, individuals show no intent to change within six months, often resisting evidence like diet's link to atherosclerosis clinging to beliefs that meds alone suffice. Contemplation involves considering change, preparation plans it, and maintenance sustains it none apply, as the client isn't pondering dietary shifts. This stage reflects unawareness or defiance, common post-surgery when focusing on recovery, not prevention. Nursing must gently challenge this, using education like explaining sodium's impact on heart strain to nudge awareness, critical for moving them toward contemplation and eventual heart-healthy habits, preventing further cardiac issues.
When documenting an assigned client's record during and at the end of the shift, the nurse must keep in mind which of the following facts?
- A. In order to get the care done for all assigned clients, the charting must be as brief as possible.
- B. The proper format, such as SOAP or PIE, as chosen by the hospital, must be adhered to.
- C. The chart is a legal document and may be all a nurse has to support care that was given if called to court.
- D. Clients need to be assessed and the care documented at least once every hour during the shift.
Correct Answer: C
Rationale: Documentation is a cornerstone of nursing practice, and recognizing the chart as a legal document is paramount. It serves as the primary evidence of care provided, protecting the nurse in legal disputes by detailing actions, observations, and client responses. If called to court, this record may be the only defense against claims of negligence or improper care, making accuracy and completeness essential. Brevity might compromise detail, undermining its legal value, while specific formats like SOAP enhance clarity but aren't the core issue. Hourly documentation isn't universally required unless specified by policy; the focus is on capturing significant events. This understanding ensures nurses document with precision, safeguarding both client care and professional accountability in a legal context.
The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
- A. Use the heel of her hand during percussion
- B. Change the child's position every 20 minutes
- C. Do percussion after the child eats and at bedtime
- D. Use cupped hands during percussion
Correct Answer: D
Rationale: Cupped hands during chest percussion loosen mucus in cystic fibrosis, creating vibrations without pain, a key physiotherapy technique to clear airways. Heel strikes are harsh, frequent repositioning isn't routine, and post-meal percussion risks reflux. Nurses teach this method for effective secretion management, improving breathing and reducing infection risk in this chronic condition.
The nurse gave pain medication to Mr. Gary even if he did not ask for it because she assessed that he is in pain. This is an example of?
- A. Autonomy
- B. Beneficence
- C. Justice
- D. Fidelity
Correct Answer: B
Rationale: Giving pain meds unasked, based on assessed need, is beneficence (B) doing good, per ethics. Autonomy (A) respects choice, justice (C) fairness, fidelity (D) promises not proactive care. B fits promoting well-being, making it correct.