Nokea
A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?
- A. Monitor gastric residuals every 4 hours.
- B. Position the client in a semi-Fowler's position.
- C. Check for tube placement by auscultating air after feeding.
- D. Warm the formula to body temperature before feeding.
Correct Answer: A
Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration.
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A healthcare provider is planning care for a client who has a latex allergy. Which of the following actions should the healthcare provider include in the plan?
- A. Use latex gloves with powder.
- B. Place a sign on the client's door.
- C. Apply oil-based lotion before donning gloves.
- D. Avoid using plastic equipment.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following is an expected reaction from a client who has just been told by the physician that his tumor is malignant and has metastasis in to several organs?
- A. Crying uncontrollably
- B. Criticizing medical care
- C. Refusing to visit visitors
- D. Asking for additional medical consultations
Correct Answer: A
Rationale: A malignant, metastatic diagnosis often triggers grief's depression stage (Kübler-Ross), with crying as a natural emotional release. Criticism, withdrawal, or seeking consultations may reflect denial or bargaining, less immediate than sorrow. Nurses expect and support this reaction, offering empathy and presence, facilitating coping as patients process a life-altering prognosis, critical for emotional care.
Which of the following therapies is based on 'learning theory'?
- A. Behaviour therapy
- B. Psychoanalytic
- C. Milieu Therapy
- D. Cognitive therapy
Correct Answer: A
Rationale: Learning theory underpins therapies that modify behavior through principles like conditioning. Behaviour therapy (choice A) directly applies learning theory, using techniques such as operant conditioning (rewards/punishments) and classical conditioning (stimulus-response pairing) to address maladaptive behaviors, like phobias or addiction. Psychoanalytic therapy (choice B) focuses on unconscious conflicts and past experiences, rooted in Freudian theory, not learning principles. Milieu therapy (choice C) emphasizes a therapeutic environment to foster social learning, but it's not strictly based on learning theory's conditioning mechanisms. Cognitive therapy (choice D) targets thought patterns to change behavior, incorporating some learning elements but primarily stemming from cognitive psychology. Choice A is correct because behaviour therapy explicitly relies on learning theory's framework, systematically altering behaviors through reinforcement or desensitization. Nurses use this in practice, such as in managing anxiety disorders with exposure techniques, highlighting its relevance in clinical settings where observable behavior change is the goal.
A client with dysphagia and at risk for aspiration needs care planning. Which intervention should the nurse include in the plan?
- A. Encourage the client to drink thickened liquids.
- B. Instruct the client to swallow with chin tucked.
- C. Provide the client with a cup with a lid.
- D. Place the client in Fowler's position for meals.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A parish nurse is planning activities for a faith-based community. What should the nurse include in these activities?
- A. Health promotion
- B. Illness prevention
- C. Referral to community smoking cessation programs
- D. Screening for chronic conditions
Correct Answer: A
Rationale: A parish nurse in a faith-based setting tailors care to the congregation's needs, weaving health into spiritual life. Including health promotion teaching nutrition or stress relief empowers members to thrive, aligning with nursing's wellness focus and faith's holistic ethos. Illness prevention, like flu shot drives, protects the group, vital in close-knit settings. Referrals to smoking cessation tap community resources, supporting behavior change, while screenings for chronic issues like hypertension catch problems early, common in adult parishioners. All fit, but health promotion anchors the plan, fostering proactive habits like exercise groups post-service that resonate with spiritual vitality. This approach leverages trust in faith settings, enhancing nursing's impact by blending physical and spiritual care, ensuring activities uplift health while honoring the community's beliefs and collective strength.