Nokea
Client has undergone Upper GI and Lower GI series. Which type of health assessment framework is used in this situation?
- A. Functional health framework
- B. Head to toe framework
- C. Body system framework
- D. Cephalocaudal framework
Correct Answer: C
Rationale: Upper and Lower GI series use a body system framework (C), targeting digestive system, per assessment types. Functional (A) assesses ADLs, head-to-toe (B) and cephalocaudal (D) are physical sweeps. C fits organ focus, making it correct.
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You are doing the evaluation step of the nursing process and find that two of the goals for the client have not been met. Which of the following actions would be best on your part?
- A. Stop working on these goals, as evaluation is the last step.
- B. Assess client's motivation for complying with the care plan.
- C. Reassess problem and then review care plan and revise as needed.
- D. Determine if the client has a knowledge deficit causing nonattainment.
Correct Answer: C
Rationale: When goals aren't met during evaluation, reassessing the problem and revising the care plan is the best action. This step identifies why outcomes like reduced swelling failed, perhaps due to an outdated intervention, and adjusts accordingly. Stopping assumes evaluation ends the process, ignoring its cyclical nature. Assessing motivation or knowledge deficits might inform revisions but isn't comprehensive without reassessment. This approach ensures care evolves with the client's condition, maintaining relevance and efficacy in the nursing process.
Application of force to another person without lawful justification is
- A. Battery
- B. Negligence
- C. Tort
- D. Crime
Correct Answer: A
Rationale: Battery is the intentional, unconsented physical contact, like striking a patient, a civil tort with legal repercussions. Negligence is unintentional harm, tort is a broader category, and crime involves criminal law. Nurses avoid battery by obtaining consent, respecting autonomy, as violations breach ethical and legal standards, risking lawsuits or discipline.
A woman who is six months pregnant is seen in antepartal clinic. She states she is having trouble with constipation. To minimize this condition, the nurse should instruct her to
- A. Increase her fluid intake to three liters/day
- B. Request a prescription for a laxative from her physician
- C. Stop taking iron supplements
- D. Take two tablespoons of mineral oil daily
Correct Answer: A
Rationale: Increased fluid intake helps prevent constipation by softening stool.
When examining the client's abdomen, the nurse will most facilitate the examination by positioning the client in which of the following ways?
- A. supine with small pillows beneath knees and head
- B. semi-Fowler's position with knees extended
- C. sitting in the chair with legs elevated
- D. supine with arms extended and hands behind head
Correct Answer: A
Rationale: Supine with pillows under knees and head relaxes abdominal muscles, aiding examination, unlike semi-Fowler's, sitting, or arms-up positions. Nurses use this for effective assessment.
The nurse questions a doctors order of Morphine sulfate 50 mg, IM for a client with pancreatitis. Which role best fit that statement?
- A. Change agent
- B. Client advocate
- C. Case manager
- D. Collaborator
Correct Answer: B
Rationale: Questioning an inappropriate order like morphine for pancreatitis, which worsens sphincter of Oddi spasm reflects the client advocate role. Nurses protect patient rights and safety by challenging harmful directives, ensuring optimal care (e.g., suggesting alternatives like meperidine). This differs from change agent (lifestyle shifts), case manager (coordination), or collaborator (teamwork), emphasizing advocacy's focus on patient well-being, a core ethical duty in nursing.