Nokea
Nurse Chona read in one nurse's notes chart this documentation: "Refused to eat and fell from bed". Which of the following is lacking in this documentation?
- A. Time of complaint, for missed and reaction on fall incurred.
- B. Referrals made on fall medications given and reasons of falling.
- C. Contents or complaints, reasons of refusing meal and nature of fall.
- D. Time of eating, medications for back pain and intense of pain.
Correct Answer: C
Rationale: The correct answer is C because the documentation lacks essential details regarding the contents of the complaints, reasons for refusing the meal, and the nature of the fall. This information is crucial for understanding the patient's condition and providing appropriate care. Choice A is not directly related to the documentation provided. Choice B is about referrals and medications, which are not mentioned in the documentation. Choice D is about eating time and medications for pain, which are also not relevant to the documentation provided. Therefore, the correct answer is C as it addresses the specific missing information in the nurse's notes.
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Nurse Mauve is now on ethical dilemma. This occurs when _______.
- A. a decision had to be made quickly under stress full situation
- B. choices are unclear
- C. there is a conflict between the nurse 's decision and that of his/her superior
- D. there is a conflict of two or more ethical principles
Correct Answer: D
Rationale: The correct answer is D because an ethical dilemma arises when there is a conflict between two or more ethical principles, leading to a difficult decision-making situation for Nurse Mauve. This involves weighing the benefits and consequences of each ethical principle to determine the best course of action. Choice A is incorrect as time pressure does not define an ethical dilemma. Choice B is incorrect because ethical dilemmas involve conflicting choices, not unclear ones. Choice C is incorrect as the conflict in an ethical dilemma is not necessarily with a superior but can be internal or with other stakeholders.
A patient undergoing mechanical ventilation in the ICU develops acute exacerbation of chronic obstructive pulmonary disease (COPD). What intervention should the healthcare team prioritize to manage the patient's exacerbation?
- A. Initiate non-invasive positive pressure ventilation (NIPPV).
- B. Administer bronchodilator medications for bronchodilation.
- C. Perform endotracheal intubation for invasive mechanical ventilation.
- D. Recommend chest physiotherapy to promote airway clearance.
Correct Answer: A
Rationale: The correct answer is A: Initiate non-invasive positive pressure ventilation (NIPPV). This intervention is prioritized as it helps improve oxygenation and ventilation in COPD exacerbation without the need for invasive mechanical ventilation, reducing the risk of ventilator-associated complications. NIPPV also decreases the work of breathing and can prevent the need for intubation. Administering bronchodilator medications (B) is important in COPD exacerbation but may not address the immediate need for ventilatory support. Endotracheal intubation (C) should be reserved for cases of respiratory failure not responding to NIPPV. Chest physiotherapy (D) may be beneficial in some cases but is not the first-line intervention for managing acute COPD exacerbation.
Which of the following is the PRIMARY reason for surgical repair of myelomeningocele? To ____________.
- A. Decrease risk of infection
- B. Correct the neurologic defect
- C. Prevent seizure disorders
- D. Prevent hydrocephalus
Correct Answer: B
Rationale: The primary reason for surgical repair of myelomeningocele is to correct the neurologic defect. This is because myelomeningocele is a type of neural tube defect where the spinal cord and its protective covering do not close properly. Surgical repair aims to close the opening in the spinal cord to prevent further damage, improve neurological function, and reduce the risk of complications such as paralysis and infection. The other choices are incorrect as they are not the primary goal of the surgery. Preventing infection (Choice A) is important but not the primary reason. Seizure disorders (Choice C) and hydrocephalus (Choice D) may be associated complications but are not the main purpose of the surgical repair.
Lillian complains of unbearable pain. Which of the following characteristics axe EMPHASIZED in a culturally sensitive nursing Care? (Select all that apply) I The expression of pain is affected by learned behavior II. Physiologically, all individuals experience pain in a similar manner, III.. Some Asian people has high response to pain medications IV. Patients should be assessed for pain regardless of overt symptomatology.
- A. III and IV
- B. I and II I
- C. I and II
- D. II and III
Correct Answer: C
Rationale: Step-by-step rationale for the correct answer (C: I and II):
1. Choice I (The expression of pain is affected by learned behavior) is correct because cultural beliefs and upbringing influence how individuals express and perceive pain.
2. Choice II (Physiologically, all individuals experience pain in a similar manner) is correct because pain perception is largely influenced by biological factors that are universal.
3. Choice III (Some Asian people have a high response to pain medications) is incorrect as it focuses on a specific cultural group, which is not a general characteristic emphasized in culturally sensitive care.
4. Choice IV (Patients should be assessed for pain regardless of overt symptomatology) is incorrect as it is not specifically related to cultural sensitivity in pain management.
A patient is prescribed a statin medication for lipid-lowering therapy. Which adverse effect should the nurse monitor closely in the patient?
- A. Muscle pain or weakness
- B. Dry cough
- C. Hypertension
- D. Hyperkalemia
Correct Answer: A
Rationale: The correct answer is A: Muscle pain or weakness. Statins can cause muscle-related side effects, including rhabdomyolysis, a severe condition that can lead to muscle pain and weakness. Monitoring for these symptoms is crucial to prevent serious complications.
B: Dry cough is not a common side effect of statins.
C: Hypertension is not directly associated with statin use.
D: Hyperkalemia is not a typical adverse effect of statins.