Nursing identifies its domain in a paradigm that includes:
- A. The person, health, environment/situation and nursing
- B. Concepts, theory, health and environment
- C. Health, person, environment and theory
- D. Nurses, physicians, models and client needs
Correct Answer: A
Rationale: Nursing's paradigm comprises person (client), health (well-being goal), environment/situation (context), and nursing (practice) a metaparadigm unifying theories like Nightingale's or Watson's. This defines nursing's scope, focusing on client care holistically. Concepts, theory, health, and environment are abstract, not a complete paradigm missing 'person' and 'nursing.' Health, person, environment, and theory swap 'nursing' for 'theory,' confusing framework with product. Nurses, physicians, models, and needs mix roles and tools, not core concepts. The person, health, environment, and nursing quartet encapsulates nursing's domain, guiding practice and research comprehensively.
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Which of the following statement is NOT true about nonmaleficence?
- A. Avoiding harm
- B. Part of nursing ethics
- C. Always prevents all harm
- D. Applies to all actions
Correct Answer: C
Rationale: Nonmaleficence avoids harm (A), is ethical (B), applies broadly (D) 'always prevents all harm' (C) isn't true, as some harm (e.g., injections) is unavoidable, per ethics. It aims to minimize, not eliminate, harm. C's absolute prevention contradicts practical care realities, making it the untrue statement.
The best diet for the client with Meniere's syndrome is one that is:
- A. High in fiber
- B. Low in sodium
- C. High in iodine
- D. Low in fiber
Correct Answer: B
Rationale: A low-sodium diet is best for Meniere's syndrome, reducing fluid retention in the inner ear, which mitigates vertigo, tinnitus, and hearing loss flare-ups. High fiber aids digestion, not ear issues; high iodine or low fiber lacks relevance here. Nurses teach this dietary shift to control symptoms, emphasizing sodium's role in fluid balance, supporting long-term management of this chronic condition.
In what phase of Nurse patient relationship does a nurse review the client's medical records thereby learning as much as possible about the client?
- A. Pre Orientation
- B. Orientation
- C. Working
- D. Termination
Correct Answer: A
Rationale: In the Pre-Orientation phase (A), the nurse reviews records to gather data about the client before meeting, preparing for interaction. Orientation (B) begins with the first encounter, building trust. Working (C) involves goal-focused collaboration, and Termination (D) ends the relationship. Pre-Orientation is distinct as it's preparatory, not interactive, aligning with Peplau's model where understanding the client starts pre-contact, making A correct.
The nurse questions a doctors order of Morphine sulfate 50 mg, IM for a client with pancreatitis. Which role best fit that statement?
- A. Change agent
- B. Client advocate
- C. Case manager
- D. Collaborator
Correct Answer: B
Rationale: Questioning a morphine order for pancreatitis exemplifies the client advocate role, where nurses safeguard patient well-being. Morphine can worsen pancreatitis by causing sphincter of Oddi spasm, unlike safer options like meperidine. By challenging this, the nurse protects the client from harm, a duty rooted in ethical codes like the ANA's. Change agents modify behaviors, case managers coordinate, and collaborators work jointly, but advocacy uniquely prioritizes patient safety over compliance. In practice, this might involve consulting the doctor for an alternative, ensuring care aligns with the patient's best interest, a critical nursing responsibility.
When recording blood pressure, the sounds which can be heard with a stethoscope placed over the artery is termed as:
- A. Wheeze
- B. Murmurs
- C. Crackle sounds
- D. Korotkoff sounds
Correct Answer: D
Rationale: Blood pressure measurement involves listening to arterial sounds via a stethoscope as the cuff deflates. These sounds, known as Korotkoff sounds, occur in five phases, starting with a tapping (systolic pressure) and fading to silence (diastolic pressure). Wheezes are respiratory sounds, murmurs relate to heart valves, and crackles indicate lung fluid none apply to blood pressure. Named after Nikolai Korotkoff, these sounds are a cornerstone of manual blood pressure assessment, ensuring accurate readings essential for diagnosing hypertension or hypotension, reflecting cardiovascular health.