Mr. Gary lost his job and feels overwhelmed. This is an example of?
- A. Crisis
- B. Illness
- C. Disability
- D. Stress
Correct Answer: A
Rationale: Job loss feeling overwhelming is a crisis (A) sudden disruption, per definition. Illness (B) is disease, disability (C) loss, stress (D) response not event-specific. A fits acute imbalance, making it correct.
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The nurse is caring for an infant with developmental dysplasia of the hip. The nurse should expect to:
- A. Prepare the infant for application of a body cast
- B. Teach the mother to keep the infant in the prone position
- C. Explain that surgery will be necessary within the first 3 months
- D. Tell the mother that the condition will correct itself without treatment
Correct Answer: A
Rationale: For developmental dysplasia of the hip (DDH), a body cast (spica) is often applied to maintain hip alignment, a common intervention post-reduction in infants, guided by orthopedics. Prone positioning, early surgery, or spontaneous correction aren't standard treatment stabilizes the joint. Nurses prepare families for this, explaining its role in preventing long-term disability, ensuring compliance and comfort.
Which of the following statement is TRUE about evaluation in nursing process?
- A. First step of the process
- B. Determines if goals are met
- C. Only done once
- D. All of the above
Correct Answer: B
Rationale: Evaluation determines if goals are met (B), per process e.g., pain reduced? Not first (A, assessment), not once (C, ongoing), not all (D) outcome-focused. B truly defines evaluation's role, making it correct.
Nurse Aida has seen her patient, Roger for the first time. She establish a contract about the frequency of meeting and introduce to Roger the expected termination. She started taking baseline assessment and set interventions and outcomes. On what phase of NPR Does Nurse Aida and Roger belong?
- A. Pre Orientation
- B. Orientation
- C. Working
- D. Termination
Correct Answer: B
Rationale: Nurse Aida and Roger are in the Orientation phase (B). This stage involves the first meeting, establishing a contract (meeting frequency, termination expectations), and initial assessments to set goals. Pre-Orientation (A) is before contact, reviewing records. Working (C) focuses on implementing plans, and Termination (D) ends the relationship. Orientation, per Peplau, sets the foundation with trust and planning, matching Aida's actions, making B correct.
A theory is a set of concepts, definitions, relationships and assumptions that:
- A. Explain a phenomenon
- B. Formulate legislation
- C. Measure nursing functions
- D. Reflect the domain of nursing practice
Correct Answer: A
Rationale: A theory e.g., Henderson's uses concepts (e.g., breathing), definitions (clarifying terms), relationships (how needs interact), and assumptions (e.g., patients seek independence) to explain phenomena like recovery. This informs nursing actions e.g., why positioning aids breathing. Formulating legislation is policy, not theory's role indirectly influenced. Measuring functions suits research, not theory's explanatory purpose. Reflecting the domain describes scope, not function explanation is active. Theories explain health-related events, providing nurses frameworks to understand and address client needs, making this the precise definition.
What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection?
- A. Use sterile gloves when obtaining urine.
- B. Open the drainage bag and pour out the urine.
- C. Disconnect the catheter from the tubing and get urine.
- D. Aspirate urine from the tubing port using a sterile syringe.
Correct Answer: D
Rationale: Aspirating urine from the tubing port with a sterile syringe is the appropriate action for obtaining a sterile urine specimen from an indwelling catheter. This maintains the closed system's integrity, minimizing infection risk by avoiding exposure to external contaminants. The port is designed for sterile sampling, ensuring the specimen reflects bladder contents accurately for testing. Using sterile gloves aids asepsis but isn't the complete action; it supports the procedure, not defines it. Opening the drainage bag introduces bacteria, risking contamination and infection. Disconnecting the catheter breaks the sterile circuit, increasing urinary tract infection likelihood contrary to best practice. Aspiration via the port, paired with aseptic technique, upholds infection control standards, ensuring patient safety and reliable diagnostic results, making it the optimal nursing action.
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