Nokea
A framework for health assessment that evaluates the effects of stressors to the mind, body and environment in relation with the ability of the client to perform ADL.
- A. Functional health framework
- B. Head to toe framework
- C. Body system framework
- D. Cephalocaudal framework
Correct Answer: A
Rationale: Functional health framework (A) assesses stressors on mind, body, and environment re: ADLs, per Gordon's model. Head-to-toe (B), body system (C), and cephalocaudal (D) focus physical order, not function. A matches description, making it correct.
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Which of the following statement best describe incident reporting?
- A. Hiding errors
- B. Reporting adverse events
- C. A patient task
- D. A routine check
Correct Answer: B
Rationale: Incident reporting is reporting adverse events (B), per nursing e.g., falls logged. Not hiding (A), not task (C), not routine (D) safety-focused. B best defines its role, improving Mr. Gary's care safety, making it correct.
Nurse Aida has seen her patient, Roger for the first time. She establish a contract about the frequency of meeting and introduce to Roger the expected termination. She started taking baseline assessment and set interventions and outcomes. On what phase of NPR Does Nurse Aida and Roger belong?
- A. Pre Orientation
- B. Orientation
- C. Working
- D. Termination
Correct Answer: B
Rationale: Nurse Aida and Roger are in the Orientation phase (B). This stage involves the first meeting, establishing a contract (meeting frequency, termination expectations), and initial assessments to set goals. Pre-Orientation (A) is before contact, reviewing records. Working (C) focuses on implementing plans, and Termination (D) ends the relationship. Orientation, per Peplau, sets the foundation with trust and planning, matching Aida's actions, making B correct.
A client is scheduled for a computed tomography (CT) of the brain with contrast. When reviewing the client's medical record, what significant finding should the nurse report to the primary healthcare provider before the diagnostic procedure?
- A. The client takes metformin daily.
- B. The client has not been nothing by mouth (NPO).
- C. The client reports an allergy to gadolinium.
- D. The client was not prescribed a bowel prep.
Correct Answer: A
Rationale: Metformin (A) is significant before a CT with contrast due to lactic acidosis risk if renal function declines from contrast dye. NPO status (B) isn't critical for brain CT. Gadolinium (C) is MRI-related, not CT. Bowel prep (D) is irrelevant. A is correct. Rationale: Contrast can impair kidneys, exacerbating metformin toxicity, requiring provider adjustment, per radiology safety protocols.
Which of the following is considered as an example of intentional tort?
- A. Malpractice
- B. Negligence
- C. Breach of duty
- D. False imprisonment
Correct Answer: D
Rationale: False imprisonment, an intentional tort, involves deliberately restricting someone's freedom, like restraining a competent patient against their will. Malpractice and negligence are unintentional torts, stemming from carelessness or failure to meet standards, not intent. Breach of duty is a negligence component, not a standalone tort. In nursing, intentional torts require purposeful action, and false imprisonment risks legal liability, emphasizing patient rights and consent in care delivery.
Marianne is now at the Defervescence stage of the fever, which of the following is expected?
- A. Delirium
- B. Goose flesh
- C. Cyanotic nail beds
- D. Sweating
Correct Answer: D
Rationale: Defervescence, fever's decline, involves vasodilation and sweating e.g., cooling as heat dissipates. Delirium (high fever), goose flesh (chills), or cyanosis (hypoxia) don't fit. Nurses anticipate sweating e.g., damp sheets in Marianne, adjusting care for comfort, per fever resolution stages.