Nokea
A nurse is admitting a new client. Which of the following steps of the nursing process is the nurse performing when formulating goals to address an identified problem?
- A. Planning
- B. Implementation
- C. Assessment
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Planning. In the nursing process, planning involves formulating goals and developing a plan of action to address the identified problems from the assessment phase. During this step, the nurse sets specific, measurable, achievable, relevant, and time-bound (SMART) goals to guide the care provided. Planning ensures that interventions are tailored to the client's unique needs and helps achieve positive outcomes. The other choices are incorrect because: B: Implementation involves carrying out the plan, C: Assessment is the initial step of gathering data, and D: Evaluation is the final step to determine the effectiveness of the interventions.
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A nurse is teaching a class about pharmacodynamics. The nurse should include that which of the following medication levels occurs when a medication is at the lowest serum concentration?
- A. Trough
- B. Peak
- C. Half-life
- D. Toxic
Correct Answer: A
Rationale: The correct answer is A: Trough. The trough level represents the lowest serum concentration of a medication in the body, usually measured just before the next dose is administered. This is important in monitoring the effectiveness and safety of the drug. Peak levels (B) indicate the highest concentration. Half-life (C) refers to the time it takes for half of the drug to be eliminated from the body. Toxic levels (D) are when the drug concentration is too high and can lead to harmful effects. Other choices are not relevant to the lowest serum concentration.
A nurse is teaching a client how to walk using a walker. After showing the client the procedure, the nurse asks the client to perform the skill. Which of the following types of teaching strategies is the nurse utilizing?
- A. Role-play
- B. Question-and-answer
- C. Discussion
- D. Return demonstration
Correct Answer: D
Rationale: The correct answer is D: Return demonstration. This teaching strategy involves the client performing the skill back to the nurse to demonstrate understanding and competence. It allows for immediate feedback and correction. Role-play (A) involves acting out a scenario, not necessarily related to skill demonstration. Question-and-answer (B) involves asking and answering questions but does not involve the client performing a skill. Discussion (C) involves exchanging ideas and opinions, not skill demonstration.
A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should further assess the client before administering medication?
- A. The client reports dizziness when ambulating to the bathroom
- B. The client reports having trouble sleeping the previous night
- C. The client ate 60% of their breakfast
- D. The client has a urine output of 400 mL for the past 8 hr
Correct Answer: A
Rationale: The correct answer is A. Dizziness when ambulating can be a sign of orthostatic hypotension, a potential side effect of antihypertensive medication. The nurse should further assess for signs of hypotension before administering the medication. Choices B, C, and D are less relevant to antihypertensive medication administration. Reporting trouble sleeping, eating 60% of breakfast, and having a urine output of 400 mL are not direct contraindications for administering antihypertensive medication.
A nurse is teaching a class about expected physiological changes in older adult clients. Which of the following changes should the nurse include?
- A. Increase in startle reflex
- B. Increase in muscle mass
- C. Decrease in body fat
- D. Decrease in systolic blood pressure
Correct Answer: A
Rationale: The correct answer is A: Increase in startle reflex. As individuals age, their neurological system undergoes changes leading to increased sensitivity and exaggerated responses, including an increase in the startle reflex. This change is attributed to alterations in neurotransmitter levels and sensory processing.
Incorrect Answers:
B: Increase in muscle mass - Muscle mass typically decreases with age due to hormonal changes and decreased physical activity.
C: Decrease in body fat - Older adults tend to experience an increase in body fat and a decrease in muscle mass, contributing to changes in body composition.
D: Decrease in systolic blood pressure - While blood pressure tends to increase with age due to changes in blood vessel elasticity and hormonal changes, a decrease in systolic blood pressure is not a common expected physiological change in older adults.
A nurse is caring for a client who is taking lisinopril (ACE inhibitor). Which of the following outcomes indicates a therapeutic effect of the medication?
- A. Improved sexual function
- B. Decreased blood pressure
- C. Increase of HDL cholesterol
- D. Prevention of bipolar manic episodes
Correct Answer: B
Rationale: The correct answer is B: Decreased blood pressure. Lisinopril is an ACE inhibitor used to treat hypertension by relaxing blood vessels, leading to decreased blood pressure. This outcome is a therapeutic effect because it helps reduce the risk of cardiovascular events. Improved sexual function (A) is not a direct effect of lisinopril. Increase of HDL cholesterol (C) is not a primary effect of ACE inhibitors. Prevention of bipolar manic episodes (D) is unrelated to the mechanism of action of lisinopril.