Nokea
During a client assessment, the healthcare provider is evaluating cranial nerve function. Which assessment finding suggests that cranial nerve II is intact?
- A. The client can hear a whisper from 1 to 2 feet away.
- B. The client can identify an object by touch.
- C. The client can shrug the shoulders against resistance.
- D. The client can read a Snellen chart from 20 feet away.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication?
- A. The client will experience increased tolerance to the drug's effects and may need a higher dose.
- B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect.
- C. The medication will be more highly protein-bound, increasing the duration of action.
- D. The therapeutic index will be increased, placing the client at greater risk for toxicity.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections?
- A. I know you are capable of giving yourself the insulin.
- B. Giving yourself the injection seems to make you nervous.
- C. When I watched you give yourself the injection, you did it correctly.
- D. Tell me what you want me to do to help you give yourself the injection at home.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client has received a new diagnosis of heart failure, and the nurse is providing dietary management education. Which instruction should the nurse include?
- A. Increase intake of foods high in potassium.
- B. Avoid foods high in sodium.
- C. Limit fluid intake to 1.5 liters per day.
- D. Increase intake of foods high in vitamin K.
Correct Answer: B
Rationale: Avoiding foods high in sodium (choice B) is essential for clients with heart failure to prevent fluid retention and decrease the strain on the heart. High sodium intake can lead to fluid buildup, exacerbating heart failure symptoms. Increasing potassium intake (choice A) can be harmful in heart failure if not monitored closely. Limiting fluid intake (choice C) may be necessary in some cases, but the specific amount should be individualized based on the client's condition. Increasing vitamin K intake (choice D) is not a primary concern in heart failure management.
What action should be implemented to prevent the formation of a sacral ulcer for an immobile client?
- A. Maintain in a lateral position using protective wrist and vest restraints.
- B. Position prone with a small pillow below the diaphragm.
- C. Raise the head and knee gatch when lying in a supine position.
- D. Transfer to a wheelchair close to the nursing station for observation.
Correct Answer: B
Rationale: Positioning the client prone with a small pillow below the diaphragm helps maintain proper alignment and provides optimal pressure relief over the sacral area, reducing the risk of developing a pressure ulcer. This position redistributes pressure away from bony prominences, such as the sacrum, which is crucial in preventing ulcer formation in immobile clients.
What is the main purpose of the working phase of the nurse-patient relationship?
- A. Establish a formal or informal contract that addresses the patient's problems.
- B. Implement nursing interventions that are designed to achieve expected patient outcomes.
- C. Develop rapport and trust so the patient feels supported, and the initial plan can be identified.
- D. Clearly identify the role of the nurse and establish the parameters of the professional relationship.
Correct Answer: B
Rationale: The main purpose of the working phase in the nurse-patient relationship is to implement nursing interventions that are specifically tailored to achieve the expected patient outcomes. During this phase, the nurse actively works with the patient to put the care plan into action and make progress towards reaching the desired health goals. It involves the application of therapeutic communication, problem-solving, and interventions to address the patient's needs. Establishing rapport and trust is typically done in the orientation phase, while defining roles and boundaries usually occurs in the introductory phase of the relationship.