Nokea
A client is preparing advance directives. Which of the following statements by the client indicates an understanding of advance directives?
- A. I cannot change my instructions once they are made
- B. My doctor will need to approve my advance directives
- C. I need an attorney to witness my signature on the advance directives
- D. I have the right to refuse treatment
Correct Answer: D
Rationale: The correct answer is D: 'I have the right to refuse treatment.' This statement indicates an understanding of advance directives because advance directives allow individuals to express their treatment preferences, including the right to refuse treatment if they choose to do so. Choice A is incorrect because individuals can update or change their advance directives as needed. Choice B is incorrect because advance directives are based on the individual's preferences, not the doctor's approval. Choice C is incorrect as witnessing an advance directive typically requires a witness who is not an attorney, depending on the state's specific requirements.
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A charge nurse is discussing the use of applying ice to a client's injured knee with a newly licensed nurse. Which of the following is a benefit of this treatment?
- A. Systemic analgesic effect
- B. Increase in metabolism
- C. Decreased capillary permeability
- D. Vasodilation
Correct Answer: C
Rationale: The correct answer is C: Decreased capillary permeability. Ice application helps decrease capillary permeability, which in turn reduces swelling and inflammation at the injury site. This vasoconstriction effect helps to limit the extent of the injury. Choices A, B, and D are incorrect. Applying ice locally does not produce a systemic analgesic effect but rather a localized numbing effect. It does not increase metabolism but rather slows down metabolic processes in the affected area. Additionally, ice application causes vasoconstriction, not vasodilation.
A nurse working at the clinic is teaching a group of clients who are pregnant on the use of nonpharmacological pain management. Which of the following is an appropriate description of the use of hypnosis during labor?
- A. Hypnosis focuses on biofeedback as a relaxation technique
- B. Hypnosis promotes increased control of pain perception during contractions
- C. Hypnosis uses therapeutic touch to reduce anxiety during labor
- D. Hypnosis provides instruction to minimize pain
Correct Answer: B
Rationale: The correct answer is B. Hypnosis during labor helps the client gain increased control over her perception of pain, allowing for better pain management during contractions. Choice A is incorrect because hypnosis and biofeedback are distinct techniques. Choice C is incorrect as therapeutic touch and hypnosis are different modalities. Choice D is incorrect as hypnosis does not simply provide instruction to minimize pain, but rather helps the individual control their perception of pain.
A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?
- A. Apply skin preparation to wound edges
- B. Cleanse the wound with normal saline
- C. Don sterile gloves
- D. Determine the client's pain level
Correct Answer: D
Rationale: The correct answer is to determine the client's pain level first. Assessing the client's pain is crucial before proceeding with any procedure, including dressing changes. This step ensures that appropriate pain management measures can be implemented, making the wound care process as comfortable as possible for the patient. Applying skin preparation to wound edges (choice A) can come after addressing the pain. While cleansing the wound with normal saline (choice B) and donning sterile gloves (choice C) are important steps in wound care, they should follow the assessment of the client's pain level to prioritize the patient's comfort and well-being.
A nurse is completing an assessment of a newborn who is 2 hours old. Which of the following findings is indicative of cold stress?
- A. Respiratory rate of 60 per minute
- B. Jitteriness of the hands
- C. Diaphoresis
- D. Bounding peripheral pulses
Correct Answer: B
Rationale: Jitteriness of the hands is a classic sign of cold stress in newborns, indicating that the infant is having difficulty maintaining a stable body temperature. Cold stress can lead to hypoglycemia and increased oxygen consumption. The other options (A, C, and D) are not directly associated with cold stress in newborns. A respiratory rate of 60 per minute may be within the normal range for a newborn. Diaphoresis (excessive sweating) and bounding peripheral pulses are not specific signs of cold stress in newborns.
A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?
- A. Paradoxical pulse
- B. Dependent edema
- C. Pericardial friction rub
- D. Substernal chest pain
Correct Answer: A
Rationale: The correct answer is A: Paradoxical pulse. Paradoxical pulse, which is a significant drop in systolic blood pressure during inspiration, indicates cardiac tamponade, a life-threatening complication of pericarditis. This finding requires immediate attention as it suggests potential compromised cardiac function. Choices B, C, and D are associated with pericarditis but do not indicate the same level of urgency as paradoxical pulse.