Nokea
A healthcare professional is assessing a client's oculomotor nerve functions. Which of the following actions should the healthcare professional take?
- A. Check the client's pupillary reaction to light
- B. Ask the client to read print from the Snellen chart
- C. Ask the client to identify different scents
- D. Use cotton to lightly touch the client's cornea
Correct Answer: A
Rationale: Checking the client's pupillary reaction to light is a key assessment to evaluate the oculomotor nerve function. The oculomotor nerve controls the pupil's constriction response to light. Choices B, C, and D are incorrect because testing vision with a Snellen chart, identifying scents, or touching the cornea are not specific assessments for oculomotor nerve function.
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How can self-injury be prevented when lifting a bedside cabinet?
- A. Standing close to the cabinet when lifting.
- B. Bending at the waist when lifting.
- C. Twisting while lifting to balance the load.
- D. Lifting with a quick motion.
Correct Answer: A
Rationale: The correct way to prevent self-injury when lifting a bedside cabinet is by standing close to the cabinet. By standing close, the individual can maintain better control and balance while lifting, reducing the risk of injury. Bending at the waist when lifting (choice B) can strain the back and lead to injury. Twisting while lifting (choice C) can also cause strain and imbalance. Lifting with a quick motion (choice D) can increase the risk of injury due to lack of control and improper body mechanics.
The nurse is caring for a 17-month-old child with acetaminophen poisoning. Which laboratory reports should the nurse review first?
- A. Prothrombin time (PT) and partial thromboplastin time (PTT)
- B. Red blood cell and white blood cell counts
- C. Blood urea nitrogen and creatinine levels
- D. Liver enzymes (AST and ALT)
Correct Answer: D
Rationale: In acetaminophen poisoning, liver damage is a significant concern due to the drug's metabolism in the liver. Monitoring liver enzymes such as AST and ALT is crucial as they indicate liver function and damage. Prothrombin time (PT) and partial thromboplastin time (PTT) (Choice A) are coagulation studies and are not the priority in acetaminophen poisoning. Red blood cell and white blood cell counts (Choice B) are not directly related to acetaminophen poisoning. Blood urea nitrogen and creatinine levels (Choice C) assess kidney function, but liver enzymes are more specific for evaluating liver damage in acetaminophen poisoning.
A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minutes and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?
- A. Notify the nursing manager.
- B. Document the client's condition and communication with the surgeon.
- C. Administer additional fluids as per standard procedure.
- D. Call the surgeon back immediately to ensure timely intervention.
Correct Answer: B
Rationale: In this scenario, the nurse should choose option B, which is to document the client's condition and communication with the surgeon. By documenting the client's condition and the communication with the surgeon, the nurse ensures legal protection and maintains continuity of care. This documentation serves as evidence of the actions taken, communication exchanged, and the rationale behind decisions made. Option A, notifying the nursing manager, may not be necessary at this stage unless there are specific institutional protocols requiring it. Administering additional fluids without further clarification may not be appropriate and could worsen the client's condition if not indicated. Calling the surgeon back immediately (option D) may disrupt the agreed-upon plan of action and fail to follow the surgeon's instructions of reassessment after an hour.
A client admitted with sudden onset of severe back pain of unknown origin. Which statement would be most effective for the nurse to use to elicit further information from this client about his pain?
- A. Tell me how you are feeling right now.
- B. Describe the pain you are experiencing.
- C. Can you tell me more about your back pain?
- D. When did the pain start and how severe is it?
Correct Answer: B
Rationale: The correct answer is B: 'Describe the pain you are experiencing.' This question is the most effective as it prompts the client to provide detailed information about the nature of the pain, including its characteristics, intensity, and location. This detailed description can help the nurse in assessing the possible cause and severity of the pain. Choices A, C, and D are not as effective as they are either too general ('Tell me how you are feeling right now'), redundant ('Can you tell me more about your back pain?'), or focused only on timing and severity ('When did the pain start and how severe is it?').
Which patient will lead the nurse to select a nursing diagnosis of Impaired physical mobility for a care plan?
- A. A patient who is completely immobile
- B. A patient who is not completely immobile
- C. A patient at risk for single-system involvement
- D. A patient who is at risk for multisystem problems
Correct Answer: B
Rationale: The correct answer is B because the nursing diagnosis of Impaired physical mobility is appropriate for a patient who has some limitations in mobility but is not completely immobile. Choice A is incorrect as a patient who is completely immobile would not have impaired physical mobility but rather no physical mobility at all. Choices C and D are also incorrect as they do not directly relate to the defining characteristics of Impaired physical mobility, which involve limitations in movement and physical activity.