Nokea
A client has been prescribed transcutaneous electrical nerve stimulation (TENS) by the primary health care provider for the relief of chronic pain. Which statement by the client would indicate to the nurse a need for further teaching regarding this pain relief measure?
- A. I understand that this will help relieve the pain.
- B. This unit will eliminate the need for taking so many pain medications.
- C. I am not real happy that I have to stay in the hospital for this treatment.
- D. I am not sure that I am going to like those electrodes attached to my skin.
Correct Answer: C
Rationale: It is not necessary for the client to remain in the hospital for this treatment. The TENS unit is a portable unit, and the client controls the system for relieving pain and reducing the need for analgesics. It is attached to the skin of the body by electrodes.
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Place the following phases of crisis in the correct sequential order. Order each response with a number from first to last, with #1 as the first phase of crisis to #4 which is the fourth phase of crisis. 1. The signs and symptoms of the General Adaptation Syndrome 2. Detachment and disorientation 3. Trying alternative methods of coping 4. The use of psychological ego defense mechanisms
- A. 3,2,1,4
- B. 1,2,3,4
- C. 4,3,2,1
- D. 4,3,1,2
Correct Answer: B
Rationale: The correct sequence of crisis phases typically follows: 1) General Adaptation Syndrome (initial stress response), 2) Detachment and disorientation (emotional response), 3) Trying alternative coping methods (problem-solving attempts), and 4) Use of psychological ego defense mechanisms (if coping fails). This reflects the progression of a crisis response.
Select the complication of a blood transfusion that is accurately paired with its preventive measure.
- A. Hemolysis: Typing and cross matching the blood and checking for ABO compatibility prior to administration
- B. Hemolysis: Insuring that the client does not have a prior history of hemolysis in the past
- C. Febrile reactions: Insuring that the client does not have a prior history of hemolysis in the past
- D. Febrile reactions: Typing and cross matching the blood and checking for ABO compatibility prior to administration
Correct Answer: A
Rationale: Hemolysis is prevented by ensuring ABO compatibility and proper typing and cross-matching to avoid immune reactions.
A 1-year-old is brought to the clinic with failure to thrive. Which assessment should the nurse prioritize?
- A. Dietary intake history
- B. Motor milestone development
- C. Head circumference
- D. Skin turgor
Correct Answer: A
Rationale: Dietary intake history is critical in failure to thrive to identify inadequate caloric intake or feeding issues, guiding intervention.
Older adults with known cardiovascular disease must balance which of the following measures for optimum health?
- A. Diet, exercise, and medication.
- B. Stress, hypertension, and pain.
- C. Mental health, diet, and stress.
- D. Social events, diet, and smoking.
Correct Answer: A
Rationale: Diet, exercise, and medication are critical for managing cardiovascular disease, as they address risk factors like cholesterol, physical fitness, and blood pressure control, directly impacting heart health.
The registered nurse, prior to the delegation of tasks to other members of the nursing care team, evaluates the ability of staff members to perform assigned tasks for the position as based on which legal consideration?
- A. The American Nurses Association's Scopes of Practice
- B. The American Nurses Association's Standards of Care
- C. State statutes
- D. Federal law
Correct Answer: C
Rationale: Delegation of tasks by a registered nurse must comply with state statutes , which define the scope of practice and delegation authority for nurses and other healthcare team members within each state. These laws ensure that tasks are delegated to individuals who are legally qualified to perform them.