Nokea
Distraction therapy is:
- A. Focusing one's attention on stimuli other than pain
- B. Cognitive reappraisal
- C. The replacement of positive images of pain with other images
- D. The use of medication and meditation
Correct Answer: A
Rationale: The focus of distraction therapy is on positive stimuli rather than negative input, helping to manage pain perception.
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The nurse is evaluating the client's ability to perform active ROM. Which illustration demonstrates the client's ability to correctly perform eversion?
- A. eversion_1.PNG
- B. eversion_2.PNG
- C. eversion_3.PNG
- D. eversion_4.PNG
Correct Answer: C
Rationale: C: Eversion is turning the foot outward. A: Shows external rotation. B: Shows internal rotation. D: Shows inversion.
The client with a new colostomy asks how to deal with gas coming from the stoma. To respond to the client's concern, the nurse should ask the client to take which action? Select all that apply.
- A. Describe the dietary intake, including types of foods.
- B. Include cruciferous vegetables in the diet daily.
- C. Decrease fluid intake to 1200 mL per 24 hours.
- D. Prick the colostomy stoma pouch with a pin.
- E. Limit intake of gas-producing carbonated sodas.
- F. In the bathroom, open the pouch clamp to release gas.
Correct Answer: A,E,F
Rationale: A: Assessing diet identifies gas-producing foods. E: Limiting carbonated drinks reduces gas. F: Releasing gas in a bathroom controls odor. B: Cruciferous vegetables increase gas. C: Reduced fluid risks dehydration. D: Pricking the pouch causes leaks and odor.
When making an occupied bed, it is important for the nurse to:
- A. keep the bed in the low position.
- B. use a bath blanket or top sheet for warmth and privacy.
- C. constantly keep side rails raised on both sides.
- D. move back and forth from one side to the other when adjusting the linens.
Correct Answer: B
Rationale: Using a bath blanket or top sheet keeps the client warm and provides privacy. Keeping the bed in the low position and working above raised side rails might strain the nurse's back. Continually moving back and forth to tuck and arrange linen is time-consuming and disorganized.
A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:
- A. the physician in charge of the case is the only person allowed to decide whether organ donation can occur.
- B. the client's legally responsible party may make the decision for organ donation for the donor if the client is unable to do so.
- C. the organ procurement organization makes the decision regarding which organs to harvest.
Correct Answer: C
Rationale: The client's legally responsible party may make the decision for organ donation if the client is unable to do so. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process regarding whether organ donation is appropriate for a specific donor.
A hospitalized adult client who routinely works from midnight until 8 a.m. has a temperature of 99.1°F at 4 a.m. The nurse determines that this is most likely due to:
- A. delta sleep
- B. slow brain waves
- C. pneumonia
- D. circadian rhythm
Correct Answer: D
Rationale: Biological rhythms that follow a cycle lasting about 24 hours are termed circadian rhythm. The sleep-wake cycle is closely linked with cardiac rhythms, such as body temperature. While a person sleeps, core body temperature drops, often reaching the 24-hour low at 4 a.m. When the sleep period shifts, temperature fluctuations also shift to match the new sleep patterns.