Nokea
A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?
- A. Use a pad and paper.
- B. Use a picture or word board.
- C. Have the family interpret needs.
- D. Devise a system of hand signals.
Correct Answer: B
Rationale: For a tracheostomy client, a picture or word board (B) is easiest, allowing quick, clear communication without speech. Paper (A) requires literacy and dexterity. Family interpretation (C) is unreliable. Hand signals (D) need setup. B is correct. Rationale: Visual aids bypass vocal limitations, enhancing autonomy, a practical solution per speech therapy standards.
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A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by:
- A. Writing down all assignments
- B. Making changes after evaluating the situation and having discussions with the staff
- C. Telling the staff nurses that she is making changes to benefit their performance
- D. Evaluating the clinical performance of each staff nurse in a private conference
Correct Answer: B
Rationale: Evaluating and discussing changes eases transition and builds trust.
The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
- A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time
- B. Reporting an APTT above 45 seconds to the physician
- C. Assessing the patient for signs and symptoms of frank and occult bleeding
- D. All of the above
Correct Answer: D
Rationale: All are critical to monitor bleeding risks and heparin efficacy.
All of the following are purpose of inflammation except
- A. Increase heat, thereby produce abatement of phagocytosis
- B. Localized tissue injury by increasing capillary permeability
- C. Protect the issue from injury by producing pain
- D. Prepare for tissue repair
Correct Answer: A
Rationale: Inflammation aims to protect and heal tissue, not hinder it. Increasing heat (A) enhances phagocytosis by boosting immune cell activity, not abating it, making this statement incorrect and the exception. Localized injury response (B) occurs as capillary permeability increases, delivering immune cells to the site. Pain (C) protects by discouraging movement, aiding healing. Preparing for tissue repair (D) is a key goal as inflammation clears debris and initiates recovery. The misstatement in A reverses the biological role of heat, which supports immune function rather than suppressing it, confirming A as the answer since it does not align with inflammation's purposes.
Which of the following statement is NOT true about pulse pressure?
- A. Pulse pressure is the difference between the systolic and diastolic pressure
- B. Normal pulse pressure is 40 mmHg
- C. Pulse pressure increases when the systolic pressure is elevated and the diastolic pressure remains the same
- D. Elderly people have decreased pulse pressure due to loss of elasticity in the blood vessels
Correct Answer: D
Rationale: Pulse pressure is systolic minus diastolic (A), typically 40 mmHg (B), and rises if systolic increases with stable diastolic (C), per cardiovascular norms. Elderly have increased pulse pressure (D) due to arterial stiffness systolic rises, diastolic may drop making D untrue. Aging widens pulse pressure, not narrows it, contradicting D, thus it's the correct answer as the false statement.
Which of the following is the appropriate nursing intervention for a patient with a terminal illness who is passing through the acceptance stage?
- A. Allowing the patient to cry
- B. Encouraging unrestricted visiting
- C. Explaining the patient what is being done
- D. Being around though not speaking
Correct Answer: D
Rationale: In Kübler-Ross's acceptance stage, patients often seek peace, preferring quiet presence over active intervention. Being nearby without speaking respects their emotional state, offering comfort without disruption. Crying aligns with earlier stages (e.g., depression), unrestricted visiting may overwhelm, and explaining procedures suits denial or bargaining. Nurses provide silent support, aligning with the patient's need for calm reflection, enhancing dignity and comfort in end-of-life care.