Nokea
Myra said 'I saw my dead grandmother here at my bedside a while ago' Budek responded 'Really? That is hard to believe, How do you feel about it?' What technique did Budek used?
- A. Disproving
- B. Disagreeing
- C. Voicing Doubt
- D. Presenting Reality
Correct Answer: C
Rationale: Budek's 'Really? That is hard to believe uses voicing doubt (C), gently questioning Myra's perception (hallucination) while exploring feelings. Disproving (A) or disagreeing (B) outright rejects (e.g., 'That's not true'). Presenting reality (D) corrects (e.g., 'She's not here'). Voicing doubt, per schizophrenia care, balances reality-testing with empathy, making C correct.
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An infant with Tetralogy of Fallot is discharged with a prescription for Lanoxin elixir. The nurse should instruct the mother to:
- A. Administer the medication using a nipple
- B. Administer the medication using the calibrated dropper in the bottle
- C. Administer the medication using a plastic baby spoon
- D. Administer the medication in a baby bottle with 1oz of water
Correct Answer: B
Rationale: Using the calibrated dropper ensures accurate dosing of Lanoxin (digoxin) elixir for an infant with Tetralogy of Fallot, critical due to its narrow therapeutic range and cardiac effects. Nipples, spoons, or dilution in bottles risk under- or overdosing. Nurses teach this method to parents, stressing precision to manage heart defects safely, preventing toxicity or inefficacy.
The thyroid hormone is responsible for
- A. Regulation of calcium
- B. Regulation of the body's metabolism
- C. Regulation of sodium
- D. Regulation of potassium
Correct Answer: B
Rationale: Thyroid hormone regulates metabolism e.g., energy use unlike calcium (parathyroid), sodium/potassium (adrenals). Nurses assess e.g., weight for function, per physiology.
The nurse is caring for a client who sustained a traumatic brain injury. Which intervention should the nurse perform to prevent an increase in intracranial pressure (ICP)?
- A. Suction the client every hour
- B. Maintain the head of the bed at 30 degrees
- C. Encourage the client to cough frequently
- D. Administer a bolus of intravenous fluids
Correct Answer: B
Rationale: Maintaining HOB at 30 degrees (B) reduces ICP by aiding venous drainage. Hourly suctioning (A) or coughing (C) raises ICP. Fluid bolus (D) may worsen it. B is correct. Rationale: Elevation optimizes cerebral perfusion pressure while minimizing ICP, per brain injury care standards, unlike actions that increase intrathoracic pressure.
A nurse working in a community health center is focusing on illness prevention for a group of young adults. Which action reflects primary prevention?
- A. Screening for sexually transmitted infections
- B. Educating about the risks of smoking
- C. Referring clients with depression to a counselor
- D. Planning care for clients with asthma
Correct Answer: B
Rationale: Primary prevention targets illness before it strikes, ideal for young adults shaping lifelong habits. Educating about smoking risks cancer, lung damage aims to deter uptake or prompt quitting, a modifiable behavior with huge impact, as smoking's a top preventable death cause. Screening for STIs is secondary, catching disease early, not stopping it. Referring depression cases or planning asthma care is tertiary, managing conditions, not preventing onset. Smoking education fits primary prevention's proactive core studies show early awareness cuts initiation rates perfect for a community setting where young adults face peer pressures. Nursing uses this to shift trajectories, reducing chronic illness odds through informed choice, a powerful, scalable action for this age group's health future.
These are nursing intervention that requires knowledge, skills and expertise of multiple health professionals.
- A. Dependent
- B. Independent
- C. Interdependent
- D. Intradependent
Correct Answer: C
Rationale: Interdependent interventions involve collaboration across health disciplines e.g., a nurse and dietician planning a high-protein diet for nephrotic syndrome. Unlike dependent (physician-ordered), independent (nurse-initiated), or intradependent (non-existent), these require shared expertise, ensuring comprehensive care. This teamwork, common in complex cases, leverages diverse skills for optimal outcomes, a staple in multidisciplinary healthcare settings.