Nokea
Nurse collecting hx & physical exam data from middle adult. Nurse should expect to find decreases in which physiologic functions? (Select all that apply.)
- A. Metabolism
- B. Ability to hear low-pitched sounds
- C. Gastric secretion
- D. Far vision
- E. Glomerular filtration
Correct Answer: A,C,E
Rationale: The correct answers are A, C, and E. As individuals age, metabolism decreases due to changes in muscle mass and activity levels. Gastric secretion decreases, leading to decreased absorption of certain nutrients. Glomerular filtration rate decreases with age, affecting kidney function. Choice B is incorrect as hearing high-pitched sounds is more commonly affected with age. Choice D is incorrect as near vision is usually affected, not far vision.
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By the 2nd post-op day
- A. a client has not achieved satisfactory pain relief. What should the nurse do next according to the nursing process?
- B. Reassess client to determine reasons for pain
- C. See whether pain lessens during next 24h
- D. Change plan to ensure adequate pain relief
- E. Teach client about pain management plan
Correct Answer: A
Rationale: Correct Answer: A
Rationale: By the 2nd post-op day, if a client has not achieved satisfactory pain relief, the nurse should follow the nursing process. This involves reassessment to identify the reasons for inadequate pain relief, which is essential for developing an effective plan to address the client's pain. The nurse should not simply wait to see if the pain lessens or immediately change the pain management plan without first understanding the underlying reasons. Additionally, teaching the client about the pain management plan may be important but not the immediate priority if the pain relief is not satisfactory. It is crucial to first assess the situation comprehensively before making any changes to the plan.
A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation?
- A. Right client
- B. Right supervision/evaluation
- C. Right direction/communication
- D. Right time
- E. Right circumstances
Correct Answer: B,C,E
Rationale: The correct answer is B, C, and E.
B: Right supervision/evaluation ensures proper oversight and assessment of tasks delegated.
C: Right direction/communication emphasizes clear instructions and effective communication.
E: Right circumstances require considering factors such as workload, staff competency, and patient condition.
A: Right client is not part of the five rights of delegation.
D: Right time is important but not specifically part of the five rights of delegation.
Nurse preparing wellness presentation for families at community center. When discussing health screenings for adolescents, which info about scoliosis should nurse include? (Select all that apply.)
- A. Scoliosis is more common in girls than in boys
- B. Loss of height is often first sign of scoliosis
- C. Scoliosis screening is essential during adolescent growth spurt
- D. Slouching is common cause of scoliosis, especially in adolescents
- E. Scoliosis is forward curvature of spine
Correct Answer: A,C
Rationale: Correct Answer: A, C
A: Scoliosis is more common in girls than in boys - This is correct. Scoliosis is indeed more prevalent in girls compared to boys, with a ratio of about 7:1.
C: Scoliosis screening is essential during adolescent growth spurt - This is correct. Screening during the adolescent growth spurt is crucial as this is when scoliosis progression is most likely to occur.
B: Loss of height is often first sign of scoliosis - This is incorrect. The first sign of scoliosis is typically asymmetry or a visible curvature of the spine.
D: Slouching is a common cause of scoliosis, especially in adolescents - This is incorrect. Slouching is not a direct cause of scoliosis; it can exacerbate existing curvature but does not cause scoliosis.
E: Scoliosis is a forward curvature of the spine - This is incorrect. Scoliosis involves a lateral (side
Charge nurse is designating room assignments for clients. Based on her knowledge of fall prevention, which client should be assigned to room closest to the nursing station?
- A. 43-year-old client post-op following laparoscopic cholecystectomy
- B. 61-year-old client being admitted for telemetry to rule out MI
- C. 50-year-old client post-op following open reduction internal fixation of ankle
- D. 79-year-old client post-op following below-the-knee amputation
Correct Answer: D
Rationale: The correct answer is D. The 79-year-old client post-op following below-the-knee amputation should be assigned to the room closest to the nursing station for fall prevention. This is because this client may have mobility challenges and an increased risk of falls due to the recent surgery and potential use of assistive devices. Placing the client closer to the nursing station allows for closer monitoring and quicker assistance in case of any fall-related incidents.
Choice A is incorrect because a 43-year-old client post-op following laparoscopic cholecystectomy is not necessarily at an increased risk for falls related to mobility issues.
Choice B is incorrect as a 61-year-old client being admitted for telemetry to rule out MI is not specifically at a higher risk for falls compared to the client post-amputation.
Choice C is incorrect as a 50-year-old client post-op following open reduction internal fixation of the ankle may have mobility limitations, but the risk of falls is typically lower compared to a client post
Nurse caring for client just admitted after falling. This client is oriented x3 & can follow directions. Which action(s) by nurse are appropriate to decrease risk of fall? (Select all that apply)
- A. Place belt restraint on him when he's sitting on bedside commode
- B. Keep bed in low position with full side rails up
- C. Ensure client's call light is within reach
- D. Provide client with nonskid footwear
- E. Complete fall-risk assessment
Correct Answer: C,D,E
Rationale: Correct Answer: C, D, E
Rationale:
C: Ensuring client's call light is within reach allows the client to easily call for assistance, reducing the risk of attempting to get up independently and potentially falling.
D: Providing the client with nonskid footwear increases traction and stability, reducing the risk of slipping and falling.
E: Completing a fall-risk assessment helps identify specific factors contributing to the client's risk of falling, allowing for tailored interventions to prevent falls.
Incorrect Choices:
A: Placing a belt restraint on the client when he's on the bedside commode is inappropriate as it restricts movement and can lead to increased agitation or attempts to remove the restraint, potentially causing a fall.
B: Keeping the bed in a low position with full side rails up can actually increase the risk of injury in case of a fall, as the client may try to climb over the rails or could become trapped between the rails and the bed.