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An adult client is on extreme pain. He is moaning and grimacing. What is the best way to assess the client's pain?
- A. Perform physical assessment
- B. Have the client rate his pain on the smiley pain rating scale
- C. Active listening on what the patient says
- D. Observe the client's behavior
Correct Answer: B
Rationale: Rating pain on a smiley scale (B) is best for an adult in extreme pain; it quantifies subjective experience, per pain assessment tools. Physical assessment (A) is secondary, listening (C) misses rating, observing (D) lacks precision. B captures intensity, making it correct.
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Which of the following statement is NOT true about delegation in nursing?
- A. Assigning tasks
- B. Retains accountability
- C. Only to doctors
- D. Follows scope
Correct Answer: C
Rationale: Delegation assigns tasks (A), retains accountability (B), follows scope (D) 'only to doctors' (C) isn't true, includes aides, per standards. C's restriction misstates delegation's range, like to Mr. Gary's team, making it untrue.
What type of patient care model is the most common for student nurses and private duty nurses?
- A. Total patient care
- B. Team nursing
- C. Primary Nursing
- D. Case management
Correct Answer: A
Rationale: Total patient care, where one nurse handles all client needs like meds and hygiene is prevalent for student nurses and private duty nurses. Students benefit from focused, hands-on learning (e.g., managing a post-op patient solo), while private nurses provide personalized attention (e.g., home care). Team nursing splits tasks, primary nursing ensures continuity, and case management coordinates, but total care's simplicity suits training and one-on-one settings. Its direct accountability fosters skill mastery, widely used in educational and private contexts.
Marianne is now at the Defervescence stage of the fever, which of the following is expected?
- A. Delirium
- B. Goose flesh
- C. Cyanotic nail beds
- D. Sweating
Correct Answer: D
Rationale: Defervescence, fever's decline, involves vasodilation and sweating e.g., cooling as heat dissipates. Delirium (high fever), goose flesh (chills), or cyanosis (hypoxia) don't fit. Nurses anticipate sweating e.g., damp sheets in Marianne, adjusting care for comfort, per fever resolution stages.
The nurse and doctor jointly planned Mr. Gary's treatment. This is an example of?
- A. Collaboration
- B. Professionalism
- C. Health literacy
- D. Care transition
Correct Answer: A
Rationale: Joint planning with doctor is collaboration (A) working together, per definition. Professionalism (B) standards, literacy (C) understanding, transition (D) moves not joint-specific. A fits teamwork, making it correct.
The physician has ordered a culture specimen from a client with a suspected urinary tract infection. The nurse is aware that the specimen should be obtained:
- A. From the first morning voiding
- B. Using a sterile cotton ball placed in the client's vaginal area
- C. From the client's indwelling catheter port
- D. During the client's midstream voiding
Correct Answer: D
Rationale: Midstream voiding provides a clean-catch urine specimen for UTI culture, minimizing contamination first voiding risks sediment, vaginal cotton is irrelevant, and catheter ports are for indwelling cases. Nurses instruct this technique, ensuring accurate pathogen identification, critical for effective treatment.