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Mr. Gary is worried about his safety after a robbery. This is an example of which Maslow's need?
- A. Physiological
- B. Safety
- C. Belongingness
- D. Self-actualization
Correct Answer: B
Rationale: Worrying about safety post-robbery is Safety (B) Maslow's second level, security needs. Physiological (A) is basic survival, belongingness (C) social, self-actualization (D) fulfillment not safety-focused. B fits protection concern, making it correct.
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It is best described as a systematic, rational method of planning and providing nursing care for individuals, families, group and community
- A. Assessment
- B. Nursing Process
- C. Diagnosis
- D. Implementation
Correct Answer: B
Rationale: The nursing process (B) is a comprehensive, systematic framework used by nurses to deliver patient-centered care. It encompasses five steps: assessment (data collection), diagnosis (identifying health problems), planning (setting goals and interventions), implementation (carrying out the plan), and evaluation (assessing outcomes). This definition matches the description in the question as a rational, organized method applicable to individuals, families, groups, and communities. Assessment (A) is only the first step, not the entire method. Diagnosis (C) is a single phase focused on problem identification, while implementation (D) is the action phase, neither encompassing the full scope described. The nursing process integrates critical thinking and evidence-based practice to ensure holistic care, making B the accurate answer reflecting its broad, systematic nature.
The nurse is performing a physical assessment on a client with a history of gout. The nurse should assess the client for:
- A. Pain and swelling of the affected joint
- B. Increased urinary output
- C. Fever with a temperature greater than 101°F
- D. Numbness in the affected extremity
Correct Answer: A
Rationale: Pain and swelling of the affected joint (often the big toe) are classic gout signs due to uric acid crystal deposits increased urine, fever, or numbness aren't typical. Nurses assess for redness and warmth, guiding anti-inflammatory treatment, critical for managing this metabolic disorder's acute flares.
The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?
- A. Suctioning is required frequently.
- B. Aspiration of gastric contents occurs when suctioning.
- C. The client's skin and mucous membranes are light pink.
- D. Excessive secretions are suctioned from a tracheostomy.
Correct Answer: B
Rationale: Tracheoesophageal fistula (TEF), a rare tracheostomy complication, involves an abnormal connection between trachea and esophagus. Aspiration of gastric contents during suctioning (B) is a definitive sign, indicating esophageal leakage into the airway. Frequent suctioning (A) or excessive secretions (D) are nonspecific. Pink skin (C) reflects good oxygenation, not TEF. B is correct. Rationale: TEF allows gastric contents to enter the trachea, detected during suctioning, requiring urgent intervention like tube adjustment or surgery, distinct from routine secretion issues, per critical care nursing.
Which of the following statement best describe patient advocacy?
- A. Ignoring patient needs
- B. Supporting patient rights
- C. A routine task
- D. A medical treatment
Correct Answer: B
Rationale: Patient advocacy is supporting patient rights (B), per nursing e.g., voicing wishes. Not ignoring (A), not routine (C), not treatment (D) rights-focused. B best defines advocacy's protective role, making it correct.
The nurse encouraged Mr. Gary to make his own care decisions. This is an example of?
- A. Empowerment
- B. Advocacy
- C. Coping
- D. Quality improvement
Correct Answer: A
Rationale: Encouraging care decisions is empowerment (A) control to patient, per definition. Advocacy (B) supports, coping (C) manages, QI (D) enhances not decision-specific. A fits patient autonomy, making it correct.