Nokea
A nurse engaged in an interaction with a patient recognizes body space zones. Which of the following would the nurse identify as the individual's personal zone?
- A. Beginning at the boundary of the intimate zone and ending at the social zone
- B. Extending outward from the border to the public zone
- C. Surrounding and protecting an individual from others, especially outsiders
- D. The most distant boundary that can be used for recognizing intruders
Correct Answer: A
Rationale: The correct answer is A because the personal zone is the space ranging from 18 inches to 4 feet from an individual, which falls between the intimate zone (0-18 inches) and the social zone (4-12 feet). This zone is where most interactions with acquaintances occur.
Choice B is incorrect because the public zone extends beyond the social zone and is typically used for public speaking or formal presentations.
Choice C is incorrect because it describes the concept of a protective or defensive space, not the personal zone.
Choice D is incorrect because the concept of recognizing intruders pertains more to territoriality and is not specific to identifying personal space zones.
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A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?
- A. The client has surgical hypoparathyroidism and positive Trousseau's sign.
- B. A client who has Clostridium difficile with acute diarrhea
- C. A client who is experiencing acute kidney injury and has urine with a low specific gravity
- D. The client who has oral cancer and reports a sore on his gums
Correct Answer: A
Rationale: The correct answer is A because the client with surgical hypoparathyroidism and positive Trousseau's sign indicates a potential life-threatening condition due to hypocalcemia. Trousseau's sign is a clinical indicator of hypocalcemia, which can lead to serious complications such as seizures and tetany. This client needs immediate intervention to prevent further complications.
Choice B is incorrect because while Clostridium difficile with acute diarrhea requires prompt treatment, it is not as immediately life-threatening as hypocalcemia. Choice C is incorrect as well, as although acute kidney injury is serious, a low specific gravity alone does not necessarily indicate an immediate threat to the client's life. Choice D is also incorrect as oral cancer with a sore on the gums, while concerning, is not an immediate priority compared to the potential life-threatening complications of hypocalcemia.
After describing the various legislative efforts to address the issue of homelessness in the United States, a nursing instructor determines that the teaching was successful when the students identify which of the following as addressing the need for a continuum of care approach?
- A. Bringing Home America Act
- B. Affordable Care Act
- C. American Recovery and Reinvestment Act
- D. McKinney-Vento Homeless Assistance Act
Correct Answer: D
Rationale: The correct answer is D: McKinney-Vento Homeless Assistance Act. This act addresses the need for a continuum of care approach by providing federal funding for homeless assistance programs that offer a range of services to individuals experiencing homelessness. It emphasizes the importance of coordination among various service providers to ensure a seamless transition from emergency shelters to permanent housing.
Choice A: Bringing Home America Act does not specifically focus on homeless assistance programs or the continuum of care approach.
Choice B: Affordable Care Act primarily focuses on healthcare reform and expanding access to healthcare services, not specifically related to addressing homelessness.
Choice C: American Recovery and Reinvestment Act aims to stimulate economic recovery through job creation and infrastructure projects, not directly related to addressing homelessness or providing a continuum of care approach.
During a therapy session, a patient is asked to rate the intensity of his current issue from 1 to 10 with 1 being complete absence of the issue and 10 being the most intense. The patient is being asked which type of question?
- A. Relationship
- B. Miracle
- C. Scaling
- D. Exception
Correct Answer: C
Rationale: The correct answer is C: Scaling. Scaling questions involve asking clients to rate the intensity of their issues on a numerical scale, just like in this scenario. This helps therapists understand the perceived severity of the problem and track changes over time. Relationship questions focus on interpersonal dynamics, miracle questions explore ideal outcomes, and exception questions inquire about times when the issue is not present. In this case, the question about rating intensity aligns best with the scaling technique.
The nurse is working with a patient whose mobility is impaired secondary to a fall that resulted in a broken hip. In addition, the patient, who has diabetes, is developing problems with vision and hearing. The patient seems increasingly withdrawn and depressed. The nurse determines that the patient is at risk for spiritual distress. Which intervention would be most appropriate?
- A. Encourage the patient to talk about significant childhood religious experiences.
- B. Offer to take the patient to a revival the nurse's church is holding in the community.
- C. Read to the patient Bible passages that seem particularly relevant to the patient's case.
- D. Explore what the mobility, sight, and hearing changes mean to the patient.
Correct Answer: D
Rationale: The correct answer is D because exploring the impact of the mobility, sight, and hearing changes on the patient allows the nurse to address the patient's holistic needs, including spiritual distress. By understanding the patient's perspective on these changes, the nurse can provide support tailored to the patient's concerns, fostering a sense of connection and understanding.
Choice A is incorrect because focusing solely on childhood religious experiences may not address the current issues the patient is facing. Choice B is inappropriate as it imposes the nurse's religious beliefs on the patient. Choice C is also incorrect as it assumes a specific religious approach without considering the patient's individual beliefs and needs.
A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority?
- A. Self-esteem–building activities
- B. Anxiety self-control measures
- C. Sleep enhancement activities
- D. Suicide precautions
Correct Answer: D
Rationale: The correct answer is D: Suicide precautions. The patient's statement indicates suicidal ideation and intent. Priority is to ensure immediate safety. Suicide precautions involve continuous monitoring, removing harmful objects, and providing a safe environment. A: Self-esteem activities, B: Anxiety measures, and C: Sleep enhancement are important, but not the priority when a patient is at risk of self-harm.