Nokea
A nurse assisting with data collection is preparing to assess the optic nerve. The nurse performs this examination by using which technique?
- A. Assessing visual acuity
- B. Inspecting the eyelids for ptosis
- C. Assessing pupil constriction
- D. Assessing ocular movements
Correct Answer: A
Rationale: The correct technique to assess the optic nerve is by testing visual acuity and visual fields through confrontation. Visual acuity involves assessing the clarity of vision, which directly correlates with the function of the optic nerve. Inspecting the eyelids for ptosis is unrelated to optic nerve assessment. Assessing pupil constriction is more related to the assessment of cranial nerves controlling eye movements, particularly the oculomotor nerve. Assessing ocular movements is related to testing the abducens, oculomotor, and trochlear nerves, not specifically the optic nerve.
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A client with dumping syndrome should..........................while a client with GERD should..........................
- A. Sit up 1 hour after meals; lie flat 30 minutes after meals
- B. Lie down 1 hour after eating; sit up at least 30 minutes after eating
- C. Sit up after meals; sit up after meals
- D. Lie down after meals; lie down after meals
Correct Answer: D
Rationale: For a client with dumping syndrome, lying down 1 hour after eating helps reduce symptoms by slowing down the movement of food through the digestive tract, aiding in symptom management. This position assists in symptom management for dumping syndrome. Conversely, for a client with GERD, sitting up at least 30 minutes after eating can help prevent the backflow of stomach acid into the esophagus, reducing reflux symptoms. This upright position is beneficial for managing GERD. Choice A is incorrect because sitting up is recommended for GERD, not dumping syndrome. Choice C is incorrect as it suggests sitting up for both conditions, which is not appropriate. Choice D is incorrect as lying down after meals is not recommended for GERD; it can worsen symptoms by promoting acid reflux.
What is the primary theory that explains a family's concept of health and illness?
- A. Health Belief Model
- B. Education Factor
- C. Family Health Belief Model
- D. Family Dynamics Model
Correct Answer: A
Rationale: The correct answer is the Health Belief Model. The Health Belief Model is a widely recognized theory that explains individuals' perceptions and behaviors related to health and illness. It considers factors such as perceived susceptibility, severity of health issues, benefits of action, and barriers to taking action. Choices B, C, and D are incorrect. Choice B, 'Education Factor,' is too general and does not specifically address a family's concept of health and illness. Choice C, 'Family Health Belief Model,' is a combination of terms and not a recognized theory. Choice D, 'Family Dynamics Model,' focuses on family interactions rather than explaining a family's concept of health and illness.
A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child?
- A. turning out the room light and closing the door
- B. tiring the child during the evening with quiet activities
- C. identifying the child's home bedtime rituals and following them
- D. encouraging visitation by friends during the evening
Correct Answer: C
Rationale: For a 4-year-old client struggling to sleep in the hospital, it is essential to identify and replicate their home bedtime rituals. This familiarity can provide comfort and promote better sleep. Turning out the room light and closing the door (Choice A) might increase the child's fear by plunging the room into darkness, making it an incorrect choice. Tiring the child with quiet activities (Choice B) is incorrect as it may stimulate rather than calm the child. Encouraging visitation by friends (Choice D) can lead to increased excitement, hindering the child's ability to fall asleep instead of promoting a restful environment.
After undergoing gastric resection, which of the following meals is most likely to cause rapid emptying of the stomach?
- A. a high-protein meal
- B. a high-fat meal
- C. a large meal regardless of nutrient content
- D. a high-carbohydrate meal
Correct Answer: D
Rationale: After gastric resection, meals high in carbohydrates are more likely to cause rapid emptying of the stomach. Carbohydrates stimulate the release of gastrin, which accelerates gastric emptying. In contrast, high-fat and high-protein meals tend to delay gastric emptying. While a large meal can slow down gastric emptying, the specific nutrient content, such as high carbohydrates, plays a significant role in promoting rapid emptying. Therefore, a high-carbohydrate meal is the correct choice as it is most likely to lead to rapid gastric emptying compared to the other options.
While a client is on total parenteral nutrition, which of the following values should the nurse monitor closely?
- A. calcium
- B. magnesium
- C. glucose
- D. cholesterol
Correct Answer: C
Rationale: Glucose should be monitored closely when a client is on total parenteral nutrition due to the high glucose concentration in the solutions. Monitoring glucose levels is crucial to prevent complications such as hyperglycemia or hypoglycemia. Calcium and magnesium are usually monitored to assess electrolyte imbalances, while cholesterol levels are not directly impacted by total parenteral nutrition. Therefore, choices A, B, and D are not the primary values that need close monitoring during total parenteral nutrition.