Nokea
An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility?
- A. Stiffness of the right ankle joint
- B. Soreness of the gums
- C. Short-term memory loss
- D. Decreased appetite
Correct Answer: A
Rationale: Joint stiffness signals early contractures or atrophy from immobility.
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Growth chart is also known as:
- A. New Ballard Scale
- B. Road to health chart
- C. Apgar Score
- D. GCS Score
Correct Answer: B
Rationale: Growth charts track child development. New Ballard Scale (choice A) assesses gestational age, not growth. Road to health chart (choice B), per WHO, plots weight-for-age, monitoring nutrition and health longitudinally. Apgar Score (choice C) evaluates newborns at birth, not growth. GCS Score (choice D, Glasgow Coma Scale) assesses consciousness. B is correct, synonymous with growth charts. Nurses use it to detect malnutrition, educate caregivers, and guide interventions, ensuring child well-being.
Which of the following meal choices is suitable for a 6-month-old infant?
- A. Egg white, formula, and orange juice
- B. Apple juice, carrots, whole milk
- C. Rice cereal, apple juice, formula
- D. Melba toast, egg yolk, whole milk
Correct Answer: C
Rationale: Rice cereal, apple juice, and formula suit a 6-month-old, aligning with early solid introduction gluten-free, digestible, and safe, per pediatric guidelines. Egg whites risk allergies, whole milk isn't recommended before 1 year, and melba toast is a choking hazard. Nurses advise this menu to support growth, avoiding allergens or hard foods, ensuring nutritional balance for this developmental stage.
Which psychological effect is commonly observed in patients experiencing immobility?
- A. Increased motivation
- B. Decreased risk of depression
- C. Increased sense of independence
- D. Increased risk of anxiety and depression
Correct Answer: D
Rationale: Immobility often increases anxiety and depression risk, as patients face mobility loss, dependence, and isolation, fostering psychological distress. Motivation and independence typically wane with restricted activity, while depression risk rises, not falls, due to these constraints. Nurses address this through emotional support and engagement, understanding that mental health declines when physical freedom is curtailed. This effect highlights the need for holistic care, blending physical interventions with psychological support to mitigate the emotional toll of immobility on patients.
Which of the following is more life threatening?
- A. BP=180/100
- B. BP=160/120
- C. BP=90/60
- D. BP=80/50
Correct Answer: D
Rationale: BP 80/50 is most life-threatening e.g., hypoperfusion risks failure vs. 180/100 (hypertension), 160/120 (severe), 90/60 (borderline). Nurses prioritize this e.g., fluids for stability, per hemodynamics.
While listening to a client's lung sounds, you hear something that you believe is not normal, and you note that it is a continuous sound. You will chart this as which of the following findings?
- A. crackles
- B. Rales
- C. adventitious sounds
- D. pleral friction rub
Correct Answer: C
Rationale: Continuous abnormal lung sounds are charted as adventitious, encompassing wheezes or rubs, unlike intermittent crackles or rales. Pleural rub is specific. Nurses document this for respiratory evaluation.