Nokea
All of the following are purpose of inflammation except
- A. Increase heat, thereby produce abatement of phagocytosis
- B. Localized tissue injury by increasing capillary permeability
- C. Protect the issue from injury by producing pain
- D. Prepare for tissue repair
Correct Answer: A
Rationale: Inflammation aims to protect and heal tissue, not hinder it. Increasing heat (A) enhances phagocytosis by boosting immune cell activity, not abating it, making this statement incorrect and the exception. Localized injury response (B) occurs as capillary permeability increases, delivering immune cells to the site. Pain (C) protects by discouraging movement, aiding healing. Preparing for tissue repair (D) is a key goal as inflammation clears debris and initiates recovery. The misstatement in A reverses the biological role of heat, which supports immune function rather than suppressing it, confirming A as the answer since it does not align with inflammation's purposes.
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This is the best patient care model when there are many nurses but few patients.
- A. Functional nursing
- B. Team nursing
- C. Primary nursing
- D. Total patient care
Correct Answer: D
Rationale: Total patient care excels with many nurses and few patients, allowing each nurse to fully address one client's needs e.g., bathing, meds, education. Functional nursing assigns tasks (e.g., one nurse for vitals), team nursing divides labor, and primary nursing focuses continuity, but ample staffing makes total care ideal. For instance, a nurse can devote time to a single ICU patient, optimizing outcomes. This model leverages resources for intensive, individualized attention, enhancing care quality in such scenarios.
A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?
- A. Use a pad and paper.
- B. Use a picture or word board.
- C. Have the family interpret needs.
- D. Devise a system of hand signals.
Correct Answer: B
Rationale: For a tracheostomy client, a picture or word board (B) is easiest, allowing quick, clear communication without speech. Paper (A) requires literacy and dexterity. Family interpretation (C) is unreliable. Hand signals (D) need setup. B is correct. Rationale: Visual aids bypass vocal limitations, enhancing autonomy, a practical solution per speech therapy standards.
The nurse enters the room to give a prescribed medication but the patient is inside the bathroom. What should the nurse do?
- A. Leave the medication at the bedside and leave the room.
- B. After a few minutes, return to that patient's room and do not leave until the patient takes the medication.
- C. Instruct the patient to take the medication and leave it at the bedside.
- D. Wait for the patient to return to bed and just leave the medication at the bedside.
Correct Answer: B
Rationale: Returning after a few minutes and staying until the patient takes the medication ensures safe administration, adhering to the 'Five Rights' right patient, drug, dose, route, and time. The nurse verifies ingestion, preventing errors like missed doses or misuse, and documents accurately. Leaving medication unattended risks it being lost, taken incorrectly, or accessed by others, violating safety protocols. Instructing without supervision assumes compliance but lacks confirmation, potentially falsifying records if the dose isn't taken. Waiting briefly then leaving it bedside still neglects oversight. Returning and remaining present balances respect for the patient's privacy with accountability, ensuring the medication reaches its intended recipient at the prescribed time, critical for treatment efficacy and legal standards in nursing practice.
Which of the following is the appropriate nursing intervention for a patient with a terminal illness who is passing through the acceptance stage?
- A. Allowing the patient to cry
- B. Encouraging unrestricted visiting
- C. Explaining the patient what is being done
- D. Being around though not speaking
Correct Answer: D
Rationale: In Kübler-Ross's acceptance stage, patients often seek peace, preferring quiet presence over active intervention. Being nearby without speaking respects their emotional state, offering comfort without disruption. Crying aligns with earlier stages (e.g., depression), unrestricted visiting may overwhelm, and explaining procedures suits denial or bargaining. Nurses provide silent support, aligning with the patient's need for calm reflection, enhancing dignity and comfort in end-of-life care.
Which of the following is NOT a contraindication in taking ORAL temperature?
- A. Quadriplegic
- B. Presence of NGT
- C. Dyspnea
- D. Nausea and Vomitting
Correct Answer: A
Rationale: Quadriplegia isn't an oral temp contraindication e.g., a paralyzed patient can hold a thermometer if alert. NGT (obstruction), dyspnea (breathing), and nausea (gagging) preclude it. Nurses opt for alternatives e.g., axillary per safety protocols.