Nokea
Nurse educator presenting on basic first aid for new home health nurses. She evaluates teaching as effective when a new nurse states that a client who has heat stroke will have which of the following?
- A. Hypotension
- B. Bradycardia
- C. Clammy skin
- D. Bradypnea
Correct Answer: A
Rationale: The correct answer is A: Hypotension. Heat stroke leads to severe dehydration and vasodilation, causing a drop in blood pressure (hypotension). Bradycardia (B), clammy skin (C), and bradypnea (D) are not characteristic of heat stroke. Bradycardia is a slow heart rate, while heat stroke typically causes tachycardia. Clammy skin is more indicative of shock or hypoglycemia, not heat stroke. Bradypnea is slow breathing, but heat stroke usually leads to rapid, shallow breathing. Therefore, hypotension is the most appropriate choice as it aligns with the physiological response to heat stroke.
You may also like to solve these questions
Nurse is talking with 45 yo client with no specific family hx of cancer or DM, about planning routine screenings. Which client statement indicates client understands how to proceed?
- A. So I don't need colon cancer procedure for another 2-3 yrs
- B. For now, I should continue to have mammogram each year
- C. B/c doctor just did pap smear, I'll come back next year for another
- D. I had my blood glucose test last year so I won't need it again till next year
Correct Answer: B
Rationale: The correct answer is B. The client's statement indicates an understanding of the recommended screening guideline for mammograms for a 45-year-old individual with no specific family history of cancer. Yearly mammograms are typically recommended starting at age 40 for early detection of breast cancer. Choice A is incorrect as colon cancer screening is recommended starting at age 45-50, not in 2-3 years. Choice C is incorrect as Pap smears are typically recommended every 3-5 years, not yearly. Choice D is incorrect as blood glucose testing is usually recommended annually for individuals at risk for diabetes.
Nurse is giving presentation about accident prevention to group of parents & toddlers. Which strategies should nurse include? (Select all that apply.)
- A. Keep toxic agents in locked cabinets
- B. Keep toilet seats up
- C. Turn pot handles toward back of stove
- D. Place safety gates across stairways
- E. Make sure balloons are fully inflated
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. A) Keeping toxic agents in locked cabinets prevents toddlers from accessing harmful substances. C) Turning pot handles toward the back of the stove prevents toddlers from accidentally pulling them down. D) Placing safety gates across stairways prevents toddlers from falling down stairs. B) Keeping toilet seats up increases the risk of toddlers falling in. E) Having balloons fully inflated poses a choking hazard. In summary, choices A, C, and D are important strategies for accident prevention, while choices B and E can actually increase risks for toddlers.
Nursing instructor explaining various stages of lifespan to students. Nurse should offer which following behavior by young adult as example of appropriate psychosocial development?
- A. Becoming actively involved in providing guidance to next generation
- B. Adjusting to major changes in roles/relationships due to losses
- C. Devoting great deal of time to establishing occupation
- D. Finding oneself 'sandwiched' between being responsible for 2 generations
Correct Answer: C
Rationale: The correct answer is C because in young adulthood, individuals typically focus on establishing their careers and developing a sense of identity. This behavior aligns with Erikson's psychosocial stage of intimacy vs. isolation. Choices A, B, and D are incorrect for a young adult's appropriate psychosocial development. A focuses on generativity, which is more typical of middle adulthood. B suggests dealing with losses, which is more aligned with later stages of life. D describes the 'sandwich generation' phenomenon, which occurs later in life when individuals are responsible for both their children and aging parents.
Nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which bed position is appropriate for safe care of this client?
- A. Supine
- B. Semi-Fowler's
- C. Semi-prone
- D. Trendelenburg
Correct Answer: B
Rationale: The correct answer is B: Semi-Fowler's. This position helps prevent aspiration during enteral tube feedings by promoting proper digestion and reducing the risk of reflux. Semi-Fowler's allows gravity to assist in the movement of food through the gastrointestinal tract, decreasing the likelihood of regurgitation. Supine (A) can increase the risk of aspiration as it may cause reflux. Semi-prone (C) and Trendelenburg (D) positions are not recommended for enteral feedings due to increased risk of reflux and aspiration.
Nurse is collecting data from mother of 1 yo. Client states her child is old enough for toilet training. Following teaching by nurse, client now states her earlier ideas have changed. She's now willing to postpone toilet training until child is older. Learning has occurred in which of following domains?
- A. Cognitive
- B. Affective
- C. Psychomotor
- D. Kinesthetic
Correct Answer: B
Rationale: The correct answer is B: Affective. Affective domain involves emotions, attitudes, and feelings. In this scenario, the mother's change in willingness to postpone toilet training shows a shift in her emotional response and attitude towards the situation. This indicates a change in the affective domain, as the mother's feelings and attitudes have been influenced by the nurse's teaching.
Choices A, C, and D are incorrect:
A: Cognitive domain involves knowledge, understanding, and thinking skills. While there may be some cognitive processing involved in the mother's decision-making, the primary change observed is in her emotions and attitudes.
C: Psychomotor domain relates to physical skills and movements, which are not the focus of the scenario.
D: Kinesthetic refers to the sense of body position and movement, which is not relevant to the mother's change in willingness to postpone toilet training.