Nokea
A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:
- A. the physician in charge of the case is the only person allowed to decide whether organ donation can occur.
- B. the client's legally responsible party may make the decision for organ donation for the donor if the client is unable to do so.
- C. the organ procurement organization makes the decision regarding which organs to harvest.
Correct Answer: C
Rationale: The client's legally responsible party may make the decision for organ donation if the client is unable to do so. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process regarding whether organ donation is appropriate for a specific donor.
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The client residing in a nursing home has bilateral weak handgrips and visual and hearing deficits. Which interventions should the nurse implement when the client is eating a meal? Select all that apply.
- A. Ask the client's permission to open containers and cut up meats on the food tray.
- B. Obtain special easy-to-hold, built-up silverware for the client to use when eating.
- C. Observe the client, but avoid providing assistance even if the client is frustrated.
- D. Help feed the client if the client is eating too slowly so food does not get too cold.
- E. Ensure that the client wears eyeglasses and hearing aids before starting to eat.
Correct Answer: A,B,E
Rationale: A: Asking permission promotes autonomy. B: Built-up silverware aids weak grips. E: Sensory aids enhance independence. C: Assistance reduces frustration. D: Feeding discourages independence.
Common problems for supervisors include all of the following except:
- A. the supervisor facilitates development of staff members.
- B. the supervisor micromanages staff members.
- C. the supervisor wants to control the style in which a staff member correctly performs a task.
- D. the supervisor does not delegate.
Correct Answer: A
Rationale: Facilitating the development of staff members is an important goal for a supervisor. Micromanagement, intolerance for individual differences in style, and inability to delegate all interfere with team building and overall effectiveness.
The nurse is evaluating the client's ability to perform active ROM. Which illustration demonstrates the client's ability to correctly perform eversion?
- A. eversion_1.PNG
- B. eversion_2.PNG
- C. eversion_3.PNG
- D. eversion_4.PNG
Correct Answer: C
Rationale: C: Eversion is turning the foot outward. A: Shows external rotation. B: Shows internal rotation. D: Shows inversion.
The nurse is transferring a client from a wheelchair to the bed. Which is the correct procedure?
- A. Pull the client toward you, and pivot him on the unaffected limb
- B. Pull the client toward you, and pivot him on the affected limb
- C. Push the client toward the bed, and pivot him on the affected limb
- D. Stand the client on both legs, and push him toward the bed
Correct Answer: A
Rationale: Pulling the client and pivoting on the unaffected limb ensures safety and leverages the client's stronger side for support.
Pain tolerance in an elderly client with cancer should:
- A. Stay the same.
- B. Decrease.
- C. Increase.
- D. Cancer should have no effect on pain tolerance for an elderly client.
Correct Answer: B
Rationale: There is potential for a lowered pain tolerance to exist with diminished adaptative capacity.