Nokea
During a Romberg test, the nurse asks the patient to assume which position?
- A. Sitting
- B. Standing
- C. Genupectoral
- D. Trendelenburg
Correct Answer: B
Rationale: The Romberg test assesses balance while standing with eyes open and closed.
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The nurse is teaching the client with insulin-dependent diabetes the signs of hypoglycemia. Which of the following signs is associated with hypoglycemia?
- A. Tremulousness
- B. Slow pulse
- C. Nausea
- D. Flushed skin
Correct Answer: A
Rationale: Tremulousness is a classic sign of hypoglycemia in insulin-dependent diabetes, resulting from the autonomic nervous system's response to low glucose, triggering adrenaline release shakiness signals urgent need for sugar. Slow pulse, nausea, or flushed skin align more with other conditions or hyperglycemia. Nurses teach this symptom for self-recognition, enabling rapid intervention with glucose sources, preventing severe outcomes like seizures, critical for diabetes management.
Which of the following is TRUE about the mechanism of action of the Aortic and Carotid bodies?
- A. If the BP is elevated, the RR increases
- B. If the BP is elevated, the RR decreases
- C. Elevated BP leads to Metabolic alkalosis
- D. Low BP leads to Metabolic acidosis
Correct Answer: B
Rationale: Aortic and carotid bodies, chemoreceptors, slow respiration when BP rises e.g., baroreceptors signal reduced need for O2 delivery. Increased RR (hypoxia), alkalosis (pH), or acidosis (metabolic) misalign. Nurses note this e.g., in hypertension for respiratory adjustments, per cardiovascular interplay.
A client with a new diagnosis of hypertension is being taught about lifestyle changes. Which of the following statements should the nurse include in the teaching?
- A. You should limit your alcohol intake to no more than one drink per day.
- B. You should increase your sodium intake to at least 2,300 mg per day.
- C. You should limit your physical activity to avoid increasing your blood pressure.
- D. You should avoid eating dairy products to help lower your blood pressure.
Correct Answer: A
Rationale: The correct statement to include in teaching a client with hypertension is to limit alcohol intake to no more than one drink per day. Excessive alcohol consumption can raise blood pressure and lead to complications. Increasing sodium intake, limiting physical activity, and avoiding dairy products are not recommended for managing hypertension. Clients with hypertension should follow a heart-healthy diet low in sodium, engage in regular physical activity, and monitor their blood pressure regularly to control hypertension effectively.
Whitney verbalizes that she is anxious that the diagnostic test might reveal laryngeal cancer. Which of the following is the most appropriate nursing intervention?
- A. Tell the client not to worry until the results are in
- B. Ask the client to express feelings and concern
- C. Reassure the client everything will be alright
- D. Advice the client to divert his attention by watching television and reading newspapers
Correct Answer: B
Rationale: Asking Whitney to express feelings (B) is most appropriate, fostering therapeutic communication, per Rogers. 'Don't worry' (A) and 'everything's alright' (C) dismiss anxiety. Diversion (D) avoids emotions. B addresses her fear, making it correct.
Which of the following statement best describe infection control?
- A. Ignoring hygiene
- B. Preventing disease spread
- C. A patient task
- D. A one-time action
Correct Answer: B
Rationale: Infection control is preventing disease spread (B), per nursing e.g., handwashing. Not ignoring (A), not task (C), not one-time (D) ongoing prevention. B best defines its protective role, like for Mr. Gary, making it correct.