Nokea
During a physical assessment, a client was diagnosed with increased temperature due to an increased basal metabolic rate (BMR). Which hormonal imbalances may the client have? Select all that apply.
- A. Cortisol
- B. Thyroid
- C. Estrogen
- D. Testosterone
Correct Answer: B
Rationale: Increased BMR with elevated temperature suggests thyroid (B) excess (hyperthyroidism), boosting metabolism. Cortisol (A) affects stress, not BMR primarily. Estrogen (C) and testosterone (D) influence other systems. B is correct. Rationale: Thyroid hormones (T3, T4) directly raise BMR and heat, a classic endocrine imbalance, per physiology, unlike other hormones with indirect effects.
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How many minutes are allowed to pass if the client had engaged in strenuous activities, smoked or ingested caffeine before taking his/her BP?
- A. 5
- B. 10
- C. 15
- D. 30
Correct Answer: D
Rationale: After activity, smoking, or caffeine e.g., raising BP 30 minutes rest ensures accuracy, per AHA guidelines. Shorter times (5-15 min) risk false highs. Nurses enforce this e.g., post-exercise delay for reliable readings, standard in clinical assessment protocols.
The nurse assesses a client at 40 weeks gestation and notes regular contractions and cervical dilatation of $6 \mathrm{~cm}$. Which actions by the nurse are important during this stage? Select all that apply.
- A. Administering the epidural injection
- B. Ensuring adequate hydration
- C. Encouraging the client to void
- D. Monitoring the condition of the fetus
Correct Answer: D
Rationale: At 40 weeks gestation with 6 cm cervical dilatation, the client is in active labor. Monitoring the fetus (D) is critical to assess for distress via heart rate patterns, a priority in labor management. Administering an epidural (A) requires an order and isn't universally needed. Ensuring hydration (B) supports labor but isn't the top action. Encouraging voiding (C) prevents bladder distension but is secondary. D is chosen. Rationale: Fetal monitoring detects hypoxia or distress, guiding interventions like position changes or delivery, per ACOG standards, outweighing comfort or supportive measures in immediacy during active labor.
Clinitest is used to assess urine for
- A. Protein
- B. Sugar
- C. Phenylketones
- D. Bilirubin
Correct Answer: B
Rationale: Clinitest detects sugar e.g., glucose in diabetes via tablet reaction, unlike acetic (protein), PKU tests (phenylketones), or bilirubin assays. Nurses use e.g., bedside for quick checks, per diagnostics.
Who was the first president of the PNA?
- A. Rosario Delgado
- B. Anastacia Giron Tupas
- C. Julita Sotejo
- D. Loreto Tupas
Correct Answer: A
Rationale: Rosario Delgado, PNA's first president in 1922, led its founding e.g., pushing licensure exams. Giron-Tupas (founder), Sotejo (educator), and Tupas differ. Her role established nursing's professional voice in the Philippines, a foundational step in its organizational history.
The nurse prepares to administer buccal medication. The medicine should be placed...
- A. On the client's skin
- B. Between the client's cheeks and gums
- C. Under the client's tongue
- D. On the client's conjunctiva
Correct Answer: B
Rationale: Buccal medication is placed between the cheeks and gums for absorption.