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In what phase of Nurse patient relationship does a nurse review the client's medical records thereby learning as much as possible about the client?
- A. Pre Orientation
- B. Orientation
- C. Working
- D. Termination
Correct Answer: A
Rationale: In the Pre-Orientation phase (A), the nurse reviews records to gather data about the client before meeting, preparing for interaction. Orientation (B) begins with the first encounter, building trust. Working (C) involves goal-focused collaboration, and Termination (D) ends the relationship. Pre-Orientation is distinct as it's preparatory, not interactive, aligning with Peplau's model where understanding the client starts pre-contact, making A correct.
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Which nursing actions will increase efficient management of client care and decrease the ramifications of the nursing shortage?
- A. Pursuing postlicensure education
- B. Becoming cross-trained in another area of the hospital
- C. Taking early retirement
- D. Implementing evidenced-based clinical pathways
Correct Answer: A
Rationale: Addressing the nursing shortage and improving client care efficiency requires strategic actions that bolster the workforce and optimize practice. Pursuing postlicensure education enhances nurses' skills and adaptability, enabling them to handle diverse patient needs effectively, thus reducing strain from shortages. Becoming cross-trained in other hospital areas increases flexibility, allowing nurses to cover gaps and maintain care continuity across units. Implementing evidence-based clinical pathways standardizes care with proven methods, streamlining processes and minimizing errors, which is crucial when staffing is limited. Coordinating services before discharge ensures smoother transitions, reducing readmissions and workload. Taking early retirement, however, exacerbates the shortage by reducing experienced staff, counteracting efficiency goals. These proactive measures collectively strengthen care delivery, mitigate shortage impacts, and support a resilient healthcare system.
Which of the following statement is NOT true about health care economics?
- A. Affects care delivery
- B. Involves funding
- C. Ignores patient needs
- D. Shapes policy
Correct Answer: C
Rationale: Economics affects delivery (A), involves funding (B), shapes policy (D) 'ignores patient needs' (C) isn't true, impacts them, per system. C's neglect contradicts economics' role, like Mr. Gary's care costs, making it untrue.
Becky has been NPO since midnight in preparation for a blood test. The adreno-cortical response is activated. Which of the following is an expected response?
- A. Low blood pressure
- B. Warm, dry skin
- C. Decreased serum sodium levels
- D. Decreased urine output
Correct Answer: D
Rationale: The adrenocortical response, triggered by fasting (NPO status), activates stress hormones like cortisol and aldosterone, conserving resources during deprivation. Decreased urine output results from aldosterone's promotion of sodium and water reabsorption in the kidneys, maintaining fluid volume and blood pressure. This adaptation counters the stress of fasting, ensuring homeostasis. Low blood pressure would oppose this, as the response aims to stabilize circulation, not reduce it. Warm, dry skin isn't typical; stress might cause cool, clammy skin from vasoconstriction, but fasting alone doesn't dictate this. Decreased serum sodium levels contradict aldosterone's sodium-retaining effect, which elevates or stabilizes sodium. Decreased urine output aligns with the body's conservation mechanism, making it the expected physiological response in this scenario, critical for nurses to recognize during patient monitoring.
An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility?
- A. Stiffness of the right ankle joint
- B. Soreness of the gums
- C. Short-term memory loss
- D. Decreased appetite
Correct Answer: A
Rationale: Joint stiffness signals early contractures or atrophy from immobility.
The nurse is aware that the normal frequency of bowel sounds is
- A. 1-5 gurgles/minute
- B. 5-35 gurgles/minute
- C. 35-60 gurgles/minute
- D. 60-100 gurgles/minute
Correct Answer: B
Rationale: Normal bowel sounds are 5-35 gurgles/minute e.g., peristalsis per norms. Less (hypoactive), more (hyperactive) differ. Nurses count e.g., 1 minute for function, per standards.