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Mr. Reyea has expressive aphasia. As a part of a long range planning. The nurse should ;
- A. Provide positive feedback when he uses the word correctly
- B. Wait for him to verbally state needs regardless of how long it may take
- C. Suggest that he get help at home because the disability is permanent
- D. Help the family to accept the fact that Mr, Reyes cannot participate in verbal communication Situation - Patricia Zeno is a client with history myasthenia gravis
Correct Answer: A
Rationale: The correct answer is A: Provide positive feedback when he uses the word correctly. In individuals with expressive aphasia, positive reinforcement helps improve communication skills. Praising Mr. Reyea when he uses words correctly encourages continued effort and boosts confidence. This approach motivates him to communicate more despite his challenges.
Summary of other choices:
B: Waiting indefinitely for Mr. Reyea to verbally state needs is not practical and may lead to frustration.
C: Suggesting permanent help at home assumes the disability cannot improve, which is not necessarily true for expressive aphasia.
D: Helping the family to accept Mr. Reyea's inability to communicate verbally may hinder his progress and limit his social interactions.
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Which finding will alert the nurse that the goal has been met?
- A. Heart rate 78 beats/min on 12/3
- B. Heart rate 78 beats/min on 12/4
- C. Heart rate 80 beats/min on 12/3
- D. Heart rate 80 beats/min on 12/4
Correct Answer: A
Rationale: The correct answer is A because it meets the goal of maintaining a heart rate of 78 beats/min. This specific date ensures the consistency of the heart rate within the desired range. Choices B, C, and D do not align with the goal as they either have a different heart rate or occur on a different date. Therefore, A is the only option that accurately reflects the goal being met on the specified date.
Mr. Sison had an above the knee amputation (AKA). He is taught to use crutches while prosthesis is being adjusted. The nurse instruct the client to support her weight primarily on which areas?
- A. axilla
- B. upper arms
- C. elbows
- D. hands
Correct Answer: A
Rationale: The correct answer is A: axilla. When using crutches, weight should primarily be supported on the axilla to prevent nerve and blood vessel damage in the armpit area. Supporting weight on the upper arms (B) can lead to nerve compression and muscle strain. Supporting weight on the elbows (C) can cause nerve damage and discomfort. Supporting weight on the hands (D) can lead to hand and wrist pain and may not provide stable support. Therefore, the axilla is the most appropriate area to support weight while using crutches to ensure safety and comfort for the client.
Which of the following hormones retains sodium in the body?
- A. Antidiuretic hormone
- B. Aldosterone
- C. Thyroid hormone
- D. Insulin
Correct Answer: B
Rationale: The correct answer is B: Aldosterone. Aldosterone is a hormone produced by the adrenal glands that helps regulate sodium and water balance in the body. It acts on the kidneys to increase reabsorption of sodium, leading to water retention and increased blood volume. This helps maintain blood pressure and electrolyte balance.
A: Antidiuretic hormone (ADH) mainly acts on the kidneys to increase water reabsorption, not sodium retention.
C: Thyroid hormone does not directly influence sodium retention.
D: Insulin regulates blood sugar levels by promoting glucose uptake, it does not have a direct role in sodium retention.
The thymus gland role with the immune system is which of the following?
- A. Maturates B cells
- B. Maturates platelets
- C. Maturates red blood cells
- D. Maturates T cells
Correct Answer: D
Rationale: The correct answer is D: Maturates T cells. The thymus gland is crucial for the maturation of T cells, a type of white blood cell that plays a central role in the adaptive immune response. T cells mature in the thymus through a process of selection and education, where they learn to distinguish self from non-self antigens. This process is essential for the development of a functional immune system. Choices A, B, and C are incorrect because the thymus gland does not play a role in the maturation of B cells, platelets, or red blood cells, respectively.
During an ophthalmic assessment, which of the ff are the nurses expected to observe carefully? Choose all that apply
- A. Level of central vision
- B. Pupil responses
- C. External eye appearance
- D. Eye movements
Correct Answer: B
Rationale: The correct answer is B: Pupil responses. During an ophthalmic assessment, observing pupil responses is crucial as it provides information on the function of the cranial nerves and potential neurological issues. Pupil size, shape, symmetry, and reaction to light are key indicators of eye health.
A: Level of central vision - While important, assessing the level of central vision is typically done by the ophthalmologist and not within the scope of the nurse's role in a routine assessment.
C: External eye appearance - Although external eye appearance can give some clues about eye health, it is not as direct and crucial as observing pupil responses.
D: Eye movements - While eye movements can provide information on ocular motor function, it is not as critical as assessing pupil responses in an ophthalmic assessment.