Nokea
Mr. Jones is being discharged today. Which of the following statements by Mr. Jones would indicate that he understands his postoperative regimen?
- A. I'm taking my nephew to the amusement park next week and we are going to ride the roller-coasters.'
- B. My brother will be coming over every day to help me with my bath and to shave me.'
- C. I think I'll watch the baseball games on TV this week rather than driving to the stadium.'
- D. I guess I'll have to take an early retirement since my job as an accountant requires me to use my eyes a lot.'
Correct Answer: C
Rationale: Avoiding strenuous activities like driving or riding roller coasters demonstrates understanding of activity restrictions necessary during recovery from retinal surgery.
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Mary asks how the pulmonary function test ordered by her physician is performed. You respond by saying
- A. You breathe into a spirometer to measure your lung capacity.
- B. You breathe through a mouthpiece into a spirometer until all air in your lungs is expelled; then you take a deep breath through the mouthpiece. This is done three times and a computer calculates the capacity of your lungs.
- C. A computer is used to measure your volume and vital capacity.
- D. A tube is inserted into your lungs while you are asleep to expand your lungs to their full capacity.
Correct Answer: B
Rationale: Pulmonary function tests measure lung capacity using spirometry.
List and briefly describe the five dimensions of pain.
- A. Biological dimension: Physiological aspects of pain
- B. Behavioral dimension: Observable responses to pain
- C. Cognitive dimension: Thought processes related to pain
- D. Emotional dimension: Psychological reactions to pain
Correct Answer: A
Rationale: The correct answer includes all five dimensions: biological, behavioral, cognitive, emotional, and sociocultural.
When examining a patient who is paralyzed below the T4 level, the medical-surgical nurse expects to find
- A. flaccidity of the upper extremities.
- B. hyperreflexia and spasticity of the upper extremities.
- C. independent use of upper extremities and efficient cough.
- D. impaired diaphragmatic function requiring ventilator support.
Correct Answer: C
Rationale: Patients paralyzed below T4 typically retain independent use of upper extremities.
15. What is the role of the professional nurse related to the use of complementary and alternative therapies (CAT) (select all that apply)?
- A. Seeking further education on CAT
- B. Evaluating the evidence regarding CAT
- C. Collecting data on the use of CAT as part of the nursing assessment
- D. Suggesting specific herbs the patient should take to help with his or her condition
Correct Answer: A
Rationale: Options A, B, and C reflect appropriate roles for nurses in relation to CAT, including seeking education, evaluating evidence, and collecting relevant data during assessments.
A 20-year-old patient with a massive head injury is on life support, including a ventilator to maintain respirations. What three criteria for brain death are necessary to discontinue life support?
- A. Irreversible cessation of all brain functions.
- B. Absence of brainstem reflexes.
- C. No spontaneous respirations.
- D. Fear of pain
Correct Answer: B
Rationale: Brain death is confirmed when there is irreversible cessation of all brain functions, absence of brainstem reflexes, and no spontaneous respirations, meeting legal and medical criteria for death.