Nokea
A healthcare provider is preparing to assess the acoustic nerve during a neurological examination. To assess this nerve, the provider uses which technique?
- A. Uses a tuning fork
- B. Asks the client to puff out the cheeks
- C. Tests taste perception on the client's tongue
- D. Checks the client's ability to clench the teeth
Correct Answer: A
Rationale: Testing of cranial nerve VIII (acoustic nerve) involves assessing hearing acuity through techniques like the whispered voice test and tuning fork tests (Weber and Rinne). Using a tuning fork helps determine if sound lateralizes to one ear (Weber) and compares air conduction to bone conduction (Rinne). Asking the client to puff out the cheeks is for cranial nerve VII (facial nerve) function evaluation. Testing taste perception on the tongue assesses cranial nerve IX (glossopharyngeal nerve) function. Checking the ability to clench teeth assesses cranial nerve V (trigeminal nerve) motor function.
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A complication of total parenteral nutrition (TPN) is the development of cholestasis. What is this condition?
- A. an inflammatory process of the extrahepatic bile ducts
- B. an arrest of the normal flow of bile
- C. an inflammation of the gallbladder
- D. the formation of gallstones
Correct Answer: B
Rationale: Cholestasis due to TPN administration is an intrahepatic process that interrupts the normal flow of bile. It is characterized by a reduction or stoppage of bile flow. Choice A, an inflammatory process of the extrahepatic bile ducts, refers to cholangitis, not cholestasis. Choice C, an inflammation of the gallbladder, describes cholecystitis, a different condition. Choice D, the formation of gallstones, is not correct as cholestasis is about the flow of bile, not the formation of gallstones.
Referral for client education in the community can be accomplished through all of the following except:
- A. community agencies such as the American Heart Association
- B. parish nurses
- C. home health care agencies
- D. unlicensed massage therapists
Correct Answer: D
Rationale: Client education should be conducted by individuals with acknowledged expertise in the subject area and appropriate credentials to support their activities within the healthcare community. Choices A, B, and C involve reputable entities or professionals who can provide accurate and reliable client education. The American Heart Association, parish nurses, and home health care agencies are recognized for their healthcare-related knowledge and qualifications. However, unlicensed massage therapists lack the necessary qualifications and expertise to deliver appropriate healthcare-related education, making them unsuitable for referrals when it comes to client education in the community.
Activities of effective supervisors can be task-related or people-related activities. An example of a task-related supervisory activity is:
- A. coaching.
- B. evaluating.
- C. delegating.
- D. facilitating.
Correct Answer: C
Rationale: Delegating is the act of assigning work to those capable and competent to do the work, making it a task-related supervisory activity. Coaching, evaluating, and facilitating are people-related supervisory activities. Coaching involves guiding and developing individuals, evaluating entails assessing performance, and facilitating focuses on enabling tasks and processes. These activities are more centered on interacting with and supporting people rather than directly assigning tasks. Therefore, in the context of task-related activities, delegating stands out as the correct choice.
The primary organ for drug elimination is the:
- A. skin
- B. lung(s)
- C. kidney(s)
- D. liver
Correct Answer: C
Rationale: The correct answer is the kidney(s) because most drugs are excreted in the urine, either as the parent compound or as drug metabolites. The skin is not the primary organ for drug elimination; only a few drugs are excreted in sweat. The lung(s) primarily excrete volatile gases with expiration, not drugs. While the liver metabolizes drugs, it is the kidney(s) that primarily eliminate drugs through urine, especially those with a molecular weight above 300.
An adolescent female reports being raped at a party where alcohol was served. The client admits to drinking alcohol before being raped by an acquaintance. The nurse should:
- A. inform the client that because she is underage, she is not at fault for attending a party where alcohol was served.
- B. ask the client if anyone witnessed the event because the client was intoxicated and might not remember it accurately.
- C. inform the client that it was not her fault, and support the client through the physical examination.
- D. question whether the woman had consensual sex and now just feels guilty.
Correct Answer: C
Rationale: In cases of rape, it is crucial to provide support and reassurance to the victim. The nurse should inform the client that it was not her fault and offer support through the physical examination. Blaming the victim, as in choice A, is inappropriate and can be damaging to the client's well-being. Choice B is not the priority at this moment; the immediate focus should be on supporting the client. Choice D is victim-blaming and implies doubt about the client's report, which is harmful and not supportive. It is essential to create a safe and supportive environment for the client to facilitate healing and recovery.