Nokea
A nurse at a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?
- A. Apply vest restraints to residents who are confused
- B. Keep all four side rails up on beds at night
- C. Accompany residents over 85 years of age during ambulation
- D. Implement rounds every 2 hours during the day to offer toileting
Correct Answer: D
Rationale: The correct answer is to implement rounds every 2 hours during the day to offer toileting. This intervention helps prevent falls by addressing the common cause of unassisted mobility, which is the need to use the bathroom. Choice A is incorrect as restraints should not be the first choice for fall prevention due to the risk of injury and loss of independence. Choice B is incorrect because all side rails up can lead to entrapment and should only be used based on individualized assessments. Choice C may not be feasible for all residents over 85 years old and does not directly address the risk of falls.
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What is the significance of patient advocacy in nursing?
- A. Prioritizing the needs of the healthcare team over the patient
- B. Ensuring that patients' rights and preferences are respected
- C. Limiting patient autonomy
- D. Focusing solely on clinical procedures
Correct Answer: B
Rationale: Patient advocacy in nursing entails ensuring that patients' rights and preferences are respected. This involves advocating for the patients' best interests, supporting informed decision-making, and safeguarding their autonomy. Choice A is incorrect because patient advocacy focuses on the patient's needs, not the healthcare team's. Choice C is incorrect as patient advocacy aims to empower patients and enhance their autonomy rather than limiting it. Choice D is incorrect since patient advocacy goes beyond clinical procedures to encompass holistic care that addresses the patients' preferences and rights.
You are working on a pediatric unit. Which toy or other diversional item or activity is most appropriate for your 18-month-old patient?
- A. Story books
- B. Beach balls
- C. An interactive play session with other children less than 2 years of age
- D. Pickup sticks
Correct Answer: B
Rationale: A beach ball is appropriate for an 18-month-old as it is safe and can help with motor skills development. Choice A, storybooks, may not be suitable for this age group due to limited attention span. Choice C involves interaction with other children which may not always be feasible in a healthcare setting. Choice D, pickup sticks, poses a choking hazard and is not suitable for toddlers.
A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?
- A. Proceed with treatment without obtaining written consent
- B. Contact the client's next of kin to obtain consent for treatment
- C. Have the client sign a consent for treatment
- D. Notify risk management before initiating treatment
Correct Answer: A
Rationale: In emergency situations where a client is disoriented and has a cardiac arrhythmia, obtaining written consent may not be possible due to the urgency of the situation. The priority is to provide immediate treatment to ensure patient safety. Contacting the next of kin or having the client sign a consent form would cause unnecessary delays in providing critical care. Notifying risk management before initiating treatment is not the most appropriate action when dealing with a time-sensitive situation like a cardiac arrhythmia.
What is an episiotomy?
- A. A surgical incision of the perineum to prevent tearing during delivery.
- B. Releasing the red plug from the cervix just before crowning occurs.
- C. An incision in the abdomen with which the baby can be delivered through.
- D. The severance of the umbilical cord between mother and child.
Correct Answer: A
Rationale: An episiotomy is a surgical incision of the perineum to prevent tearing during delivery. This procedure is performed to widen the vaginal opening and facilitate childbirth. Choice B is incorrect as it describes the expulsion of the mucus plug, not an episiotomy. Choice C is incorrect as it refers to a different procedure, a cesarean section, where the baby is delivered through an incision in the abdomen. Choice D is incorrect as it pertains to cutting the umbilical cord, which is not related to an episiotomy.
Your client is adversely affected with fever, night sweats, occult hematuria, tenderness of the spleen, and Osler's nodes. What disorder would you most likely suspect?
- A. Tuberculosis
- B. AIDS/HIV
- C. Pericarditis
- D. Endocarditis
Correct Answer: D
Rationale: The client is likely suffering from endocarditis based on the symptoms described. Endocarditis is characterized by fever, night sweats, hematuria, splenomegaly (tenderness of the spleen), and Osler's nodes (painful nodules on the pads of the fingers or toes). While tuberculosis and AIDS/HIV can present with some similar symptoms, the presence of Osler's nodes is more specific to endocarditis. Pericarditis typically presents with chest pain, not the combination of symptoms seen in this case.