Nokea
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.
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After a head injury, a client develops a deficiency of antidiuretic hormone (ADH). What should the nurse consider before assessing the patient about the response to secretion of ADH?
- A. Serum osmolality increases
- B. Urine concentration decreases
- C. Glomerular filtration decreases
- D. Tubular reabsorption of water increases
Correct Answer: B
Rationale: ADH deficiency (diabetes insipidus) post-head injury causes dilute urine (B) due to reduced water reabsorption. Osmolality increases (A) is a result, not a cause. GFR (C) isn't primarily affected. Reabsorption (D) decreases. B is correct. Rationale: Low ADH leads to polyuria with low urine concentration, a key assessment in DI, per endocrine trauma care.
The coronary vessels, unlike any other blood vessels in the body, respond to sympathetic stimulation by
- A. Vasoconstriction
- B. Vasodilatation
- C. Decreases force of contractility
- D. Decreases cardiac output
Correct Answer: B
Rationale: The coronary vessels are unique because they respond to sympathetic stimulation with vasodilatation, unlike most other blood vessels which constrict. Sympathetic stimulation activates the fight-or-flight response, increasing heart rate and oxygen demand. To meet this demand, the coronary arteries dilate to supply more blood to the heart muscle. Vasoconstriction (A) is incorrect as it would reduce blood flow, countering the heart's needs during stress. Decreases in force of contractility (C) or cardiac output (D) are unrelated to the vascular response and pertain more to myocardial function, not the coronary vessels' behavior. This vasodilatation is mediated by beta-adrenergic receptors, ensuring adequate perfusion during heightened activity, making B the correct choice.
Which of the following activities on the part of the nurse most demonstrates individualization of the nursing-care plan for a client?
- A. Include client's preferred times of care and methods used.
- B. Write the care plan instead of taking it off the computer.
- C. Use a care plan from a book but add some things to it.
- D. Select nursing diagnoses that match the client's problems
Correct Answer: A
Rationale: Individualizing a care plan is best shown by including the client's preferred times and methods, tailoring care to their unique needs and lifestyle. For instance, scheduling baths when a client feels most rested respects their routine, enhancing comfort and compliance. Writing plans manually or adapting generic ones lacks this personal touch, while matching diagnoses is standard, not individualized. This approach reflects client-centered care, ensuring interventions like wound care timing fit the individual, boosting effectiveness and satisfaction.
Which of the following statement is TRUE about palliative care?
- A. Palliative care is given only on Hospice setting
- B. Palliative care is given only to cancer clients
- C. Palliative care improves quality of life
- D. Palliative care is offered only when the client's condition is irreversible
Correct Answer: C
Rationale: Palliative care improves quality of life (C), per its goal managing symptoms, enhancing comfort. It's not hospice-only (A), not cancer-specific (B), and applies beyond irreversible states (D) available at any serious illness stage. C's universal truth aligns with palliative principles, making it correct.
Mr. Gary died yesterday, His wife is not talking to anyone and prefers to be alone staring blankly at her husband's picture. This is an example of?
- A. Denial
- B. Anger
- C. Bargaining
- D. Depression
Correct Answer: D
Rationale: Not talking, staring blankly post-death is depression (D), per Kubler-Ross withdrawal, sadness dominate. Denial (A) disputes, anger (B) lashes, bargaining (C) negotiates all absent. Depression fits her isolation, making it correct.