Nokea
It is important that Nurse Chona records accurately the restless caused by pain and that of hypoxia. Which of the following should be recorded as the restlessness caused by pain?
- A. Difficulty of breathing.
- B. Increased respiratory rate and blood pressure.
- C. Increased heart rate.
- D. Increased perspiration and change of position.
Correct Answer: D
Rationale: Restlessness caused by pain often manifests as increased perspiration and constant change of position. When a person is in pain, they may become sweaty or clammy due to increased sympathetic nervous system activity. Additionally, they may constantly shift or fidget in an attempt to find a more comfortable position that can alleviate the pain they are experiencing. Therefore, it is crucial for Nurse Chona to accurately document these behaviors as signs of pain-related restlessness. Difficulty of breathing (Option A), increased respiratory rate and blood pressure (Option B), and increased heart rate (Option C) are more indicative of hypoxia or respiratory distress rather than pain-related restlessness.
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Which BEST describes the planning function of Nurse Ellen in her role as nurse manager?
- A. Get and develop people to do work
- B. Distributes and arranges work to ensure smooth operation of the unit.
- C. Determines the actual performance compared with the desired output.
- D. Determine how to achieve the mandate of work.
Correct Answer: D
Rationale: The planning function of Nurse Ellen in her role as a nurse manager best corresponds to option D, which is to determine how to achieve the mandate of work. Planning involves setting objectives, developing strategies, and outlining the steps to accomplish those objectives. As a nurse manager, Nurse Ellen would be responsible for creating plans to ensure the effective delivery of patient care, efficient allocation of resources, and meeting the organizational goals of the unit. By determining how to achieve the work mandate, Nurse Ellen can effectively lead her team, allocate resources efficiently, and navigate any challenges that may arise in the operation of the nursing unit.
A patient presents with tremors, rigidity, bradykinesia, and postural instability. On examination, the patient demonstrates a shuffling gait, stooped posture, and a masked facies. Which of the following neurological conditions is most likely responsible for these symptoms?
- A. Alzheimer's disease
- B. Parkinson's disease
- C. Multiple sclerosis (MS)
- D. Amyotrophic lateral sclerosis (ALS)
Correct Answer: B
Rationale: The symptoms described in the patient, such as tremors, rigidity, bradykinesia (slow movement), and postural instability, along with the presence of a shuffling gait, stooped posture, and masked facies, are classic features of Parkinson's disease. These motor symptoms are primarily caused by the degeneration of dopamine-producing neurons in the substantia nigra region of the brain. This results in an imbalance of neurotransmitters, particularly dopamine, leading to motor dysfunction and characteristic movement abnormalities seen in Parkinson's disease.
Which of the following interventions is most appropriate for a patient experiencing an acute asthma exacerbation with severe respiratory distress and hypoxemia?
- A. Administration of high-flow oxygen via nasal cannula
- B. Initiation of non-invasive positive pressure ventilation (NIPPV)
- C. Nebulized albuterol/ipratropium combination therapy
- D. Intravenous corticosteroid therapy
Correct Answer: B
Rationale: In a patient experiencing an acute asthma exacerbation with severe respiratory distress and hypoxemia, the most appropriate intervention is to initiate non-invasive positive pressure ventilation (NIPPV). NIPPV can help improve ventilation, decrease work of breathing, and correct hypoxemia by providing positive pressure to keep the airways open, reduce air trapping, and increase the elimination of carbon dioxide. This intervention can help improve oxygenation and reduce the need for invasive mechanical ventilation in patients with severe asthma exacerbations. Administering high-flow oxygen via nasal cannula alone may not provide enough support for patients with severe respiratory distress. Nebulized albuterol/ipratropium combination therapy and intravenous corticosteroid therapy are also important treatments for asthma exacerbations but are not the first-line interventions for patients with severe respiratory distress and hypoxemia.
A pregnant woman presents with vaginal bleeding and passage of tissue at 10 weeks gestation. On examination, the cervix is dilated, and products of conception are visualized in the cervical os. Which of the following conditions is the most likely cause of these symptoms?
- A. Ectopic pregnancy
- B. Threatened abortion
- C. Placenta previa
- D. Complete abortion
Correct Answer: D
Rationale: Complete abortion is the most likely cause of the symptoms described. In a complete abortion, all products of conception are expelled from the uterus. Symptoms include vaginal bleeding, passage of tissue, and dilation of the cervix. In this scenario, the presentation of a dilated cervix with visualized products of conception is classic for a complete abortion at 10 weeks gestation.
A nurse is caring for a patient with limited mobility and is planning interventions to prevent pressure injuries. What action by the nurse demonstrates evidence-based practice in pressure injury prevention?
- A. Applying moisturizing lotion to the patient's skin daily
- B. Turning and repositioning the patient every 2 hours
- C. Placing the patient on an alternating pressure mattress
- D. Massaging the bony prominences to improve circulation
Correct Answer: C
Rationale: Placing the patient on an alternating pressure mattress demonstrates evidence-based practice in pressure injury prevention. Alternating pressure mattresses are designed to change pressure points by alternating pressure across different parts of the body, reducing the risk of pressure injuries. Regularly turning and repositioning the patient (Choice B) is also important in preventing pressure injuries, but an alternating pressure mattress provides additional support and prevention measures. Applying moisturizing lotion (Choice A) and massaging bony prominences (Choice D) may be beneficial for skin care, but they are not proven strategies for pressure injury prevention.