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If a nurse observes a sudden change in a client's vital signs, what immediate step should the nurse take?
- A. Inform the physician
- B. Change the environmental settings of the client
- C. Alter the diet intake of the client
- D. Decrease the physical activity of the client
Correct Answer: A
Rationale: Immediate medical attention is necessary for significant changes in vital signs.
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Which of the following positions would be most comfortable for Mr. Tucker?
- A. Supine with head elevated 20-30° and knees flexed
- B. Prone with head turned to side and feet extending over mattress edge
- C. Flat on back with the bed gatched in the middle
- D. Supine with a hard thick pillow under the lumbar region
Correct Answer: A
Rationale: This position reduces strain on the back muscles.
Nurse Williams is conducting a seminar on dementia for the staff at the senior care facility. She emphasizes the importance of understanding the most prevalent causes of dementia in the elderly population. Which condition does Nurse Williams identify as the most common cause of dementia among elderly individuals?
- A. Amyotrophic lateral sclerosis
- B. Alzheimer's disease
- C. Multiple sclerosis
- D. Parkinson's disease
Correct Answer: B
Rationale: Alzheimer's disease is the most common cause of dementia in the elderly, characterized by progressive memory loss and cognitive decline.
The resting potential indicates that the inside of the neuron is ________ compared to the outside.
- A. under ionic pressure
- B. positive
- C. negative
- D. inactive
Correct Answer: C
Rationale: The resting potential of a neuron, typically around -65mV, indicates that the inside of the neuron is negatively charged compared to the outside. This charge difference is maintained by the sodium-potassium pump and the selective permeability of the cell membrane to ions. The resting potential is essential for the neuron's ability to generate and transmit nerve impulses, as it provides the electrical gradient necessary for action potentials.
The patient who is aphasic frequently reacts with anger or depression to his inability to communicate. A therapeutic approach to this behavior is to
- A. anticipate his needs to minimize efforts to talk
- B. respect his need to grieve
- C. express recognition of his difficulty and efforts to communicate
- D. keep verbal stimulation to a minimum
Correct Answer: C
Rationale: Acknowledging efforts encourages communication attempts.
The first priority of care of the patient with a new fracture includes assessing
- A. Respiratory rate and effort, pulse.
- B. The fracture site for bleeding.
- C. For signs of infection at the wound site of an open fracture.
- D. For circulation and sensation distal to the fracture site.
Correct Answer: D
Rationale: Assessing circulation and sensation ensures no neurovascular compromise has occurred due to the fracture.