Considered as Safest and most non invasive method of temperature taking
- A. Oral
- B. Rectal
- C. Tympanic
- D. Axillary
Correct Answer: D
Rationale: Axillary temp is safest, least invasive no mucosal entry e.g., armpit avoids rectal (perforation), oral (biting), or tympanic (ear) risks. Ideal for infants, nurses use it e.g., frail patients for safety, per non-invasive guidelines.
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While giving a shift report on your assigned client, you realize that you forgot to record a nursing procedure done on your client. Which of the following methods of documentation would be best on your part?
- A. Write the procedure between the two lines of your shift documentation closest to the occurrence.
- B. Find a blank space in your earlier charting, and chart the procedure in that space.
- C. Tell the oncoming nurse to chart the procedure for you and to cite the time it was done.
- D. Chart the current date and time and 'Late entry,' indicating when and what was done.
Correct Answer: D
Rationale: A late entry with current date, time, and details of the missed procedure is best, maintaining accuracy and legality. Inserting between lines or blank spaces risks confusion, and delegating falsifies records. This method ensures transparency, critical for nursing accountability and care continuity.
Nurse Aida has seen her patient, Roger for the first time. She establish a contract about the frequency of meeting and introduce to Roger the expected termination. She started taking baseline assessment and set interventions and outcomes. On what phase of NPR Does Nurse Aida and Roger belong?
- A. Pre Orientation
- B. Orientation
- C. Working
- D. Termination
Correct Answer: B
Rationale: Nurse Aida and Roger are in the Orientation phase (B). This stage involves the first meeting, establishing a contract (meeting frequency, termination expectations), and initial assessments to set goals. Pre-Orientation (A) is before contact, reviewing records. Working (C) focuses on implementing plans, and Termination (D) ends the relationship. Orientation, per Peplau, sets the foundation with trust and planning, matching Aida's actions, making B correct.
The country where SHUSHURUTU originated
- A. China
- B. Egypt
- C. India
- D. Babylonia
Correct Answer: C
Rationale: Shushurutu, an ancient surgical text from India (circa 1000 BCE), details procedures like cataract surgery, rooted in Ayurveda. Unlike China, Egypt, or Babylonia, India's medical tradition birthed this, shaping early knowledge. Nursing traces such origins, as ancient practices inform modern care and historical context.
The nurse is caring for a client with a T4 spinal cord injury. Which finding indicates that the client is experiencing neurogenic shock?
- A. Blood pressure 82/40 mm Hg, pulse 48 beats/min
- B. Blood pressure 150/90 mm Hg, pulse 110 beats/min
- C. Blood pressure 110/70 mm Hg, pulse 88 beats/min
- D. Blood pressure 130/80 mm Hg, pulse 62 beats/min
Correct Answer: A
Rationale: Neurogenic shock in T4 SCI features hypotension and bradycardia (A, 82/40, 48 bpm) from sympathetic loss. Hypertension/tachycardia (B) suggests dysreflexia. C and D are normalish. A is correct. Rationale: Loss of vasomotor tone below T4 causes vasodilation and unopposed vagal activity, per SCI pathophysiology, requiring fluids and atropine.
Type of respiration that occurs when there is an increase in depth and rate of respiration usually seen in people who engages in strenuous exercise.
- A. Kussmaul's breathing
- B. Eupnea
- C. Hyperpnea
- D. Bradypnea
Correct Answer: C
Rationale: Hyperpnea (C) is increased depth and rate of respiration, common in strenuous exercise, per respiratory terminology. Kussmaul's (A) is deep, rapid breathing in metabolic acidosis, not exercise. Eupnea (B) is normal breathing, and bradypnea (D) is slow. Hyperpnea matches the physiological response to heightened oxygen demand during activity, making C the correct answer based on its specific context.