Nokea
Accurate documentation of assessment findings regarding pressure ulcers is very important because:
- A. The law requires the nurse to document lesions
- B. The hospital requires the nurse to document lesions
- C. The physician requires the nurse to document lesions
- D. The nursing assessment of ulcers is a standard of nursing practice
Correct Answer: D
Rationale: Documenting pressure ulcers is a nursing standard to promote continuity of care and prevent progression, not merely a legal or institutional requirement.
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A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:
- A. assessment.
- B. crisis intervention.
- C. empathetic concern.
- D. unwarranted intrusion.
Correct Answer: B
Rationale: Choice 2 is part of the Crisis Intervention Model. Counseling by a nurse specialist at the time of a stressful event (rape) can strengthen the client's coping. A nurse specialist in rape crisis intervention is educationally prepared in counseling and crisis intervention specific to rape victims.
Which of these would be an appropriate meal for a client with Celiac disease?
- A. egg noodles with cream sauce and broccoli, oat cookie, almond milk
- B. turkey sandwich with rye bread, carrots
- C. chicken and rice, apple, and tapioca pudding
- D. granola and dried apricots with cow's milk
Correct Answer: C
Rationale: Rice, fruits, vegetables, meat, dairy, and tapioca are all safe gluten-free options. Oats can be a gluten-free food if they are specially labeled, but many are processed on the same equipment as wheat and so they should not automatically be considered a safe item. Unless marked, granola typically contains oats that could have been exposed to gluten. While fresh fruit is safe, dried and prepackaged fruits may contain additives that contain gluten. Rye is wheat derivative, and many cream sauces contain flour as a base.
A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:
- A. the physician in charge of the case is the only person allowed to decide whether organ donation can occur.
- B. the client's legally responsible party may make the decision for organ donation for the donor if the client is unable to do so.
- C. the organ procurement organization makes the decision regarding which organs to harvest.
Correct Answer: C
Rationale: The client's legally responsible party may make the decision for organ donation if the client is unable to do so. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process regarding whether organ donation is appropriate for a specific donor.
A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as:
- A. plantar fasciitis.
- B. hallux valgus.
- C. hammertoe.
- D. Morton's neuroma.
Correct Answer: D
Rationale: Morton's neuroma is a small mass or tumor in a digital nerve of the foot. Hallux valgus is referred to in lay terms as a bunion. Hammertoe is where one toe is cocked up over another toe. Plantar fasciitis is an inflammation of, or pain in, the arch of the foot.
What is the most effective way to prevent skin breakdown?
- A. assistive devices
- B. repositioning
- C. topical medications
- D. avoiding tape and Bandaids™
Correct Answer: B
Rationale: Repositioning is the most effective way to prevent skin breakdown.