Nokea
A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which type of immunity?
- A. Natural immunity
- B. Acquired immunity
- C. Passive immunity
- D. Cell-mediated immunity
Correct Answer: B
Rationale: An immunization functions as part of acquired immunity. Acquired immunity involves the production of antibodies after immunization, which helps protect against future infections. Natural immunity is not induced by immunization but is present from birth. Passive immunity is temporary and acquired through the transfer of pre-formed antibodies. Cell-mediated immunity is a type of immune response that involves the activation of phagocytes, antigen-specific cytotoxic T-lymphocytes, and the release of various cytokines in response to an antigen.
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A nurse is preparing a client for transfer to another unit. Which finding should the nurse include in the transfer report?
- A. Nutritional status
- B. Client's response to pain medication
- C. Daily vital signs
- D. Most recent lab results
Correct Answer: B
Rationale: The correct answer is B: Client's response to pain medication. When transferring a client to another unit, it is crucial to communicate how the client is responding to pain medication to ensure continuity of care and appropriate pain management. While nutritional status, daily vital signs, and most recent lab results are important aspects of the client's care, the client's response to pain medication directly impacts their comfort and well-being during the transfer process.
A nurse is caring for a client who has dementia and frequently tries to get out of bed. What actions should the nurse take? (Select all that apply)
- A. Turn off the bed alarm
- B. Use physical restraints
- C. Maintain the bed in the lowest position
- D. Apply a vest restraint
Correct Answer: C
Rationale: Maintaining the bed in the lowest position is an appropriate action when caring for a client with dementia who tries to get out of bed. This helps reduce the risk of falls and ensures the client's safety. Turning off the bed alarm (Choice A) is not advisable as it can be a safety measure to alert the staff when the client tries to get out of bed. Using physical restraints (Choice B) and applying a vest restraint (Choice D) should be avoided as they can lead to physical and psychological harm, reduce mobility, and compromise the client's dignity.
A nurse is completing an admission assessment for a client who has hearing loss. What action should the nurse take?
- A. Use written communication
- B. Speak louder than usual
- C. Face the client when speaking
- D. Provide care in a quiet environment
Correct Answer: A
Rationale: Using written communication is the most effective action for a nurse when assessing a client with hearing loss. This method helps overcome communication barriers by providing information visually, ensuring the client understands the assessment questions and instructions. Speaking louder (choice B) may distort the sound and not necessarily improve understanding. Facing the client (choice C) is important for lip reading but may not be sufficient for effective communication. Providing care in a quiet environment (choice D) is beneficial but might not fully address the need for clear communication in the assessment process for a client with hearing loss.
A charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. The charge nurse should identify that the nurse is accountable for which of the following torts?
- A. Negligence
- B. Assault
- C. Battery
- D. Defamation
Correct Answer: A
Rationale: The correct answer is A: Negligence. Negligence in nursing occurs when a healthcare provider fails to take appropriate action that a reasonably prudent provider would take in a similar situation, such as not notifying the provider of changes in a client's condition. In this scenario, the nurse's failure to inform the provider of the client's changed condition constitutes negligence. Choices B, C, and D are incorrect. Assault involves the intentional threat of bodily harm to another person, battery is the intentional harmful or offensive touching of another person without their consent, and defamation is the act of making false statements about someone to a third party that harms that person's reputation.
A nurse in a provider's office is assessing the motor skill development of a 15-month-old toddler during a well-child visit. What gross motor skill should the nurse expect?
- A. Jumps with both feet
- B. Runs with coordination
- C. Walks without assistance
- D. Kicks a ball forward
Correct Answer: C
Rationale: At 15 months, a toddler should be able to walk without assistance. Walking without assistance is a major gross motor skill milestone at this age, indicating the child's physical development and coordination. Choices A, B, and D are developmentally inappropriate for a 15-month-old. Jumping with both feet, running with coordination, and kicking a ball forward typically develop later in a child's growth and are more advanced skills compared to walking independently.