Nokea
During the detoxification stage, it is a priority for the nurse to:
- A. teach skills to recognize and respond to health threatening situations
- B. increase the client¢â‚¬â„¢s awareness of unsatisfactory protective behaviors
- C. implement behavior modification
- D. promote homeostasis and minimize the client¢â‚¬â„¢s withdrawal symptoms
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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You are on morning duty in the medical ward. You have 10 patients assigned to you. During your endorsement rounds, you found out that one of your patients was not in bed. The patient next to him informed you that he went home without notifying the nurses. Which among the following will you do first?
- A. Make an incident report
- B. Call security to report the incident
- C. Wait for 2 hours before reporting
- D. Report the incident to your supervisor
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During times of staff and financial shortage, which method is the best and most effective?
- A. Functional Method
- B. Primary Nursing
- C. Team Nursing
- D. Modular Method
Correct Answer: D
Rationale: During times of staff and financial shortage, the Modular Method is considered the best and most effective. This method allows for flexibility and adaptability in assigning tasks and responsibilities, making it easier to cope with limited resources. Functional Method (Choice A) focuses on the division of labor based on each staff member's skills, which may not be the most efficient during shortages. Primary Nursing (Choice B) and Team Nursing (Choice C) may require a more significant number of staff, making them less suitable during shortages.
For an incontinent elderly client who frequently wets his bed and develops redness and skin excoriation at the perianal area, what is the best nursing goal?
- A. Ensure that the bed linen is always dry
- B. Frequently check the bed for wetness and keep it dry
- C. Place a rubber sheet under the client's buttocks
- D. Keep the patient clean and dry
Correct Answer: A
Rationale: The best nursing goal for an incontinent elderly client with skin excoriation is to ensure that the bed linen is always dry. This helps in preventing further skin breakdown and promoting skin integrity. Choice B, to frequently check the bed for wetness and keep it dry, may not address the issue of prevention if the linen is not consistently dry. Choice C, placing a rubber sheet under the client's buttocks, focuses more on protecting the mattress rather than addressing the client's skin condition directly. Choice D, keeping the patient clean and dry, is important but does not specifically address the preventive aspect of maintaining dry bed linen.
A nurse is caring for a client with a thiamine deficiency. Which assessment findings will the nurse expect?
- A. Tachycardia, muscle weakness, and lack of coordination
- B. Swollen lips, cracks in the corners of the mouth, and glossitis
- C. Neuropsychiatric symptoms of delusions and hallucinations
- D. Scaly rash on arms, dementia, and diarrhea
Correct Answer: A
Rationale: Thiamine deficiency, also known as Vitamin B1 deficiency, can present with various symptoms. Tachycardia, muscle weakness, and lack of coordination are classic signs of thiamine deficiency due to its role in energy metabolism. Swollen lips, cracks in the corners of the mouth, and glossitis are more indicative of a deficiency in riboflavin (Vitamin B2). Neuropsychiatric symptoms of delusions and hallucinations are characteristic of niacin (Vitamin B3) deficiency. A scaly rash on the arms, dementia, and diarrhea are not typically associated with thiamine deficiency. Therefore, the correct assessment findings for a client with thiamine deficiency are tachycardia, muscle weakness, and lack of coordination.
Mrs. Pichay who is for thoracentesis is assigned by the nurse to any of the following positions, EXCEPT:
- A. straddling a chair with arms and head resting on the back of the chair
- B. lying on the unaffected side with the bed elevated 30-40 degrees
- C. lying prone with the head of the bed lowered 15-30 degrees
- D. sitting on the edge of the bed with her feet supported and arms and head on a padded overhead table
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.