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After a walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea, the nurse takes the client's vital signs. What phase of the nursing process is being implemented by the nurse?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
Correct Answer: A
Rationale: In this scenario, the nurse is performing the assessment phase of the nursing process. Assessment involves collecting data, which includes obtaining vital signs, to identify the client's health status and needs. This step is crucial for the nurse to gather information that will guide further decision-making in the nursing process.
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Which type of illness is characterized by severe symptoms of relatively short duration?
- A. Chronic Illness
- B. Acute Illness
- C. Pain
- D. Syndrome
Correct Answer: B
Rationale: Acute illnesses are characterized by the sudden onset of severe symptoms that typically last for a short duration. These conditions usually resolve within a defined period, unlike chronic illnesses that persist over a longer time frame. Pain and syndrome are not specific types of illnesses but rather symptoms or clinical manifestations that can occur in various health conditions.
Which of the following clusters of data belong to Maslow's hierarchy of needs?
- A. Love and belonging
- B. Physiological needs
- C. Self-actualization
- D. All of the above
Correct Answer: D
Rationale: Maslow's hierarchy of needs is a theory in psychology that categorizes human needs into five levels. These levels, from the most fundamental to the highest, are physiological needs, safety needs, love and belongingness, esteem needs, and self-actualization. Therefore, all the clusters listed in the choices - love and belonging, physiological needs, and self-actualization - correspond to different levels within Maslow's hierarchy of needs. Choosing 'All of the above' (option D) is the correct answer as it includes all the clusters associated with Maslow's theory.
The client was asked to read the Snellen chart. Which of the following is being tested?
- A. Optic
- B. Olfactory
- C. Oculomotor
- D. Trochlear
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a seizure, what is the primary intervention?
- A. Protect the patient from injury
- B. Insert an airway
- C. Elevate the head of the bed
- D. Withdraw all pain medications
Correct Answer: A
Rationale: The primary intervention during a seizure is to protect the patient from injury. This includes moving nearby objects that may harm the patient, cushioning the head, and ensuring a safe environment until the seizure subsides. Inserting an airway is not typically done during a seizure unless the patient's airway is compromised, while elevating the head of the bed is not the priority during an active seizure. Withdrawing all pain medications is not necessary unless there are specific contraindications related to the seizure event.
When preparing to administer an IM injection that is irritating to the subcutaneous tissue, what is the best action to prevent tracking of the medication?
- A. Use a small gauge needle
- B. Apply ice on the injection site
- C. Administer at a 45° angle
- D. Use the Z-track technique
Correct Answer: D
Rationale: The Z-track technique is the best action to prevent tracking of the medication when administering an IM injection that is irritating to the subcutaneous tissue. This technique involves pulling the skin to the side before administering the injection and then releasing the skin after the injection. By doing so, a zig-zag pathway is created, preventing the medication from leaking into the subcutaneous tissue and reducing irritation.