Nokea
A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first?
- A. Asking the client to wiggle their toes
- B. Medicating the client with the prescribed analgesic
- C. Realigning the client
- D. Removing some of the traction weights
Correct Answer: C
Rationale: When a client in skeletal traction complains of pain, the priority action for the nurse is to realign the client. Severe pain may indicate the need for realignment or that the traction weights are too heavy. Realigning the client should be the initial response as it can help alleviate the pain by ensuring proper alignment. Asking the client to wiggle their toes may not address the underlying issue causing the pain. Removing traction weights should never be done unless specifically ordered by the healthcare provider as it can affect the traction's effectiveness. Medicating the client with analgesics should only be considered after attempting to address the cause of the pain, which in this case, is realignment.
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The healthcare provider is using Cognitive-Behavioral methods of pain control and knows that these methods can be expected to do all the following except:
- A. completely relieve all pain.
- B. provide benefit by restoring the client's sense of self-control.
- C. help the client to control symptoms.
- D. help the client actively participate in his or her care.
Correct Answer: A
Rationale: Cognitive-Behavioral methods of pain control aim to provide benefit by restoring the client's sense of self-control, helping the client to control symptoms, and encouraging the client to actively participate in their care. However, these methods are not intended to completely relieve all pain. These interventions focus on perception and thought, aiming to influence how one interprets events and bodily sensations. Therefore, the correct answer is that they cannot completely relieve all pain, as pain relief is often a multifaceted approach that may require additional interventions beyond Cognitive-Behavioral methods. Choices B, C, and D are correct as Cognitive-Behavioral methods are designed to empower the individual in managing their pain and improving their overall well-being.
The physician's role in case management includes all of the following except:
- A. participating in interdisciplinary planning for clients.
- B. serving as the expert for resource utilization.
- C. consulting with the case management team to facilitate timely orders as needed.
- D. contributing to the documentation of a client's needs for services.
Correct Answer: B
Rationale: The correct answer is 'serving as the expert for resource utilization.' While physicians play a crucial role in case management, their primary focus is on medical diagnosis and treatment rather than resource utilization. Choices A, C, and D are all roles that physicians typically fulfill in case management. A physician participating in interdisciplinary planning for clients ensures comprehensive care, consulting with the case management team helps in coordinating timely orders, and contributing to the documentation of a client's needs for services aids in providing appropriate care. Therefore, serving as the expert for resource utilization does not align with the primary responsibilities of a physician in case management.
When suctioning a client, what is the usual amount of time the nurse should spend for each suction pass?
- A. 2 seconds
- B. 10 seconds
- C. 20 seconds
- D. 30 seconds
Correct Answer: B
Rationale: Ten seconds is the usual amount of time the nurse should spend for each suction pass. Two seconds is not enough time to effectively remove secretions, while 20 and 30 seconds are too long and could lead to hypoxia and tissue trauma. Therefore, the correct choice is 10 seconds, as it strikes a balance between removing secretions adequately and minimizing the risks associated with prolonged suctioning.
A nurse is reading the nurse practice act for the state in which she is employed. The nurse uses the information in this act for which purpose?
- A. To understand hospital and long-term care facility policies
- B. To know the scope of practice for nurses
- C. To identify health care policies in her state
- D. To be aware of the role of the licensed nurse
Correct Answer: D
Rationale: The correct answer is 'To be aware of the role of the licensed nurse.' Nurse practice acts outline the scope of practice for nurses, defining what constitutes nursing practice and the role of licensed nurses. Choice A is incorrect because hospital and long-term care facility policies are institution-specific and not typically covered in the nurse practice act. Choice B is incorrect as the scope of practice for nurses is a part of the nurse practice act, but it's not the sole purpose for a nurse to refer to it. Choice C is incorrect as health care policies in a state are governed by other legislative acts, not the nurse practice act.
What condition is mammography used to detect?
- A. pain
- B. tumor
- C. edema
- D. epilepsy
Correct Answer: B
Rationale: Mammography is specifically used to detect tumors or abnormal growths, especially in breast tissue. It is not a tool for identifying pain, edema, or epilepsy. Therefore, the correct answer is 'tumor.' Pain is a symptom, edema is swelling, and epilepsy is a neurological disorder; none of these are conditions typically detected through mammography.