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A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered?
- A. Advil
- B. Anasaid
- C. Clinocil
- D. Colace
Correct Answer: D
Rationale: The correct answer is Colace. Colace is a stool softener that helps relieve constipation by drawing more water into the bowel, making the stool softer and easier to pass. This is beneficial for an immobilized client as it can help prevent constipation due to decreased mobility. Options A, B, and C (Advil, Anasaid, Clinocil) are not indicated for constipation relief. Advil and Anasaid are nonsteroidal anti-inflammatory drugs used for pain relief, while Clinocil is a fictional medication.
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As part of a routine health screening, the nurse notes the play of a 2-year-old child. Which of the following is an example of age-appropriate play at this age?
- A. builds towers with several blocks
- B. tries to color within the lines
- C. says 'Mine!' when playing with toys
- D. tries to jump rope
Correct Answer: C
Rationale: The correct answer is C: 'says 'Mine!' when playing with toys.' At the age of 2, children are in the stage of parallel play and are possessive of their belongings, hence saying 'Mine!' is an age-appropriate behavior. Building towers with blocks (choice A) involves more advanced motor skills and cognitive abilities, which are beyond what most 2-year-olds can do. Trying to color within the lines (choice B) requires fine motor skills that are typically not developed at age 2. Jumping rope (choice D) involves coordination and balance that are beyond the capabilities of a 2-year-old child.
An appraisal of self-care practices involves an assessment of:
- A. all diagnostic tests.
- B. home treatment practices, including nurse visits for the sick or disabled.
- C. the family's capability to get health insurance.
- D. caregiving needs and the potential for strain.
Correct Answer: D
Rationale: An appraisal of self-care practices focuses on assessing caregiving needs and the potential for strain. This involves evaluating the support system in place for individuals requiring care, the level of strain experienced by caregivers, and the overall impact of caregiving responsibilities on both the caregiver and the care recipient. The other options presented do not directly relate to the assessment of self-care practices. Diagnostic tests, home treatment practices, and the family's capability to obtain health insurance are important aspects of healthcare but do not specifically pertain to the evaluation of self-care practices.
What is the primary theory that explains a family's concept of health and illness?
- A. Health Belief Model
- B. Education-School-Completing Factor
- C. Family Health Expert Factor
- D. Disconnected Family Factor
Correct Answer: A
Rationale: The correct answer is the Health Belief Model. This model explains a family's concept of health and illness by focusing on readiness factors, perceived susceptibility, and seriousness of health problems, and positive motivation for wellness. The Health Belief Model is widely used in healthcare to understand and predict health behaviors. Choices B, C, and D are incorrect as they do not specifically address how a family perceives health and illness. The Health Belief Model is the most appropriate choice as it is specifically designed to explain individual and family beliefs and behaviors related to health and illness.
A nurse is preparing to assess the function of a client's spinal accessory nerve. Which action does the nurse ask the client to take to aid assessment of this nerve?
- A. Smiling
- B. Clenching the teeth
- C. Shrugging the shoulders against the nurse's resistance
- D. Identifying by taste a substance placed on the back of the tongue
Correct Answer: C
Rationale: To assess cranial nerve XI (spinal accessory nerve), the examiner checks the sternomastoid and trapezius muscles for equal size. Equal strength is assessed by asking the client to rotate the head forcibly against resistance applied to the side of the chin and by asking the client to shrug the shoulders against resistance. These movements should feel equally strong on the two sides. The client is asked to smile as a test of the function of cranial nerve VII (facial nerve). The client's ability to clench the teeth is used to assess the motor function of cranial nerve V (trigeminal nerve). The client's taste perception is used to assess the sensory function of cranial nerve IX (glossopharyngeal nerve). Therefore, the correct action to assess the spinal accessory nerve is to ask the client to shrug the shoulders against resistance. The other options are used to assess different cranial nerves, making them incorrect choices.
While assisting with data collection of an adult client, a nurse asks the client to identify various odors. In this technique, which cranial nerve is the nurse assessing?
- A. Optic
- B. Abducens
- C. Olfactory
- D. Hypoglossal
Correct Answer: C
Rationale: The correct answer is 'Olfactory.' The olfactory nerve is responsible for the sense of smell. Assessing this nerve involves testing the client's ability to identify various odors. Loss of smell, head trauma, abnormal mental status, and suspected intracranial lesions are conditions where testing the olfactory nerve is essential. The optic nerve is evaluated for visual acuity and visual fields. The abducens nerve is usually assessed alongside the oculomotor and trochlear nerves, focusing on pupil size, regularity, light reactions, accommodation, and extraocular movements. The hypoglossal nerve is examined by inspecting the tongue, not by assessing the sense of smell.