Nokea
In a Hispanic patient who claims to have empacho, what assessment findings would the nurse expect?
- A. Abdominal pain and cramping
- B. Anxiety,insomnia anorexia and social isolation
- C. Nightmares weakness and a sense of suffocation
- D. Headaches,stomach problems and loss of consciousness
Correct Answer: A
Rationale: Empacho is a folk illness commonly reported among Hispanic populations, characterized by abdominal pain and cramping due to perceived blockage in the digestive system.
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A client with deep vein thrombosis (DVT) is receiving heparin therapy. What is the priority assessment for the nurse?
- A. Monitoring blood pressure
- B. Checking the activated partial thromboplastin time (aPTT)
- C. Assessing for signs of bleeding
- D. Measuring calf circumference
Correct Answer: C
Rationale: The correct answer is C: Assessing for signs of bleeding. This is the priority assessment because heparin therapy increases the risk of bleeding. Signs of bleeding include bruising, petechiae, blood in urine or stool, and excessive bleeding from wounds. Monitoring blood pressure (A) is important but not the priority in this situation. Checking aPTT (B) is important for evaluating the effectiveness of heparin therapy but does not take precedence over assessing for bleeding. Measuring calf circumference (D) is used to detect changes in calf size due to DVT but is not the priority assessment while the client is on heparin therapy.
What best describes Mrs. West’s change in vital signs postoperatively?
- A. Decrease in BP indicates shock is imminent
- B. Elevated temperature indicates wound infection
- C. Decrease in BP is consistent with hypertension
- D. Elevation in temperature is consistent with normal postoperative recovery
Correct Answer: D
Rationale: A mild fever is common after surgery due to inflammatory response.
A healthcare professional wishes to provide client-centered care in all interactions. Which action by the healthcare professional best demonstrates this concept?
- A. Assesses for cultural influences affecting healthcare
- B. Ensures that all the client's basic needs are met
- C. Informs the client and family about all upcoming tests
- D. Thoroughly orients the client and family to the room
Correct Answer: A
Rationale: The correct answer is A because assessing for cultural influences affecting healthcare aligns with client-centered care by recognizing the individual's unique beliefs and values. This action promotes respect, understanding, and tailored care. Choice B might address physical needs but not necessarily emotional or cultural aspects. Choice C focuses on information sharing rather than understanding the client's perspective. Choice D, while important, does not directly address individualized care based on cultural factors.
What statement by Mr. Ross indicates postural drainage has been effective?
- A. ‘I have been able to eat a little better during the past week.’
- B. ‘I have not gained any during the past week.’
- C. ‘I have not been able to sleep very well at night.’
- D. ‘I have been bringing up lots of sputum when I cough.’
Correct Answer: D
Rationale: Effective postural drainage clears secretions, evidenced by productive coughing.
Place the steps for removal of a foreign body from the ear canal in the correct order.
- A. Refer for treatment of external otitis.
- B. Inspect the tympanic membrane for trauma.
- C. Obtain history for type of object.
- D. Choose appropriate fluid for irrigation or instillation.
Correct Answer: C
Rationale: Obtaining a history helps determine the safest method for removing the foreign body and prevents further injury.