Nokea
Palpating the midclavicular line is the correct technique for assessing
- A. Baseline vital signs
- B. Systolic blood pressure
- C. Respiratory rate
- D. Apical pulse
Correct Answer: D
Rationale: The midclavicular line locates the apical pulse at the heart's apex.
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Which of the following statement is NOT true about wellness?
- A. A dynamic process
- B. Focuses on optimal function
- C. Same with health
- D. Requires balance
Correct Answer: C
Rationale: Wellness is dynamic (A), optimal function-focused (B), balanced (D) not same as health (C), per theory. Wellness is proactive, health a state. C's identity is untrue, making it the correct false statement.
A nurse provides care to clients of a community clinic that serves a large immigrant population. Which intervention reflects primary prevention for this group?
- A. Screening for tuberculosis
- B. Providing vaccinations
- C. Referring clients with hypertension to a specialist
- D. Teaching clients with diabetes foot care
Correct Answer: B
Rationale: Primary prevention stops illness before it starts, vital for immigrants facing unique risks. Providing vaccinations like measles or flu shots builds immunity, preventing outbreaks in a group often under-vaccinated due to access or prior country norms, a top nursing action in clinics. Screening for tuberculosis is secondary, catching disease early, common in immigrant health but not preventive. Referring hypertension cases or teaching diabetic foot care is tertiary, managing existing conditions, not averting onset. Vaccinations align with primary prevention's proactive stance data shows they cut infectious disease rates in such populations addressing environmental and social vulnerabilities. Nursing leverages this to protect community health, ensuring immigrants, often in crowded settings, dodge preventable illnesses, a practical, impactful step for this clinic's focus.
Mr. Gary named his wife to make decisions if he can't. This is an example of?
- A. Health care proxy
- B. Living will
- C. Patient education
- D. Care transition
Correct Answer: A
Rationale: Naming his wife for decisions is a health care proxy (A) chosen surrogate, per definition. Living will (B) states wishes, education (C) teaches, transition (D) moves not proxy-specific. A fits Mr. Gary's delegation of authority, making it correct.
Nurse Aida has seen her patient, Roger for the first time. She establish a contract about the frequency of meeting and introduce to Roger the expected termination. She started taking baseline assessment and set interventions and outcomes. On what phase of NPR Does Nurse Aida and Roger belong?
- A. Pre Orientation
- B. Orientation
- C. Working
- D. Termination
Correct Answer: B
Rationale: Nurse Aida and Roger are in the Orientation phase (B). This stage involves the first meeting, establishing a contract (meeting frequency, termination expectations), and initial assessments to set goals. Pre-Orientation (A) is before contact, reviewing records. Working (C) focuses on implementing plans, and Termination (D) ends the relationship. Orientation, per Peplau, sets the foundation with trust and planning, matching Aida's actions, making B correct.
The nurse is caring for a client receiving oxygen therapy via a simple face mask. Which nursing intervention is important to prevent skin breakdown?
- A. Changing the position of the mask every 2 hours
- B. Applying a protective barrier cream to the client's face
- C. Padding the pressure points on the client's face with soft material
- D. Encouraging the client to remove the mask intermittently for facial skin care
Correct Answer: C
Rationale: Padding pressure points with soft material (C) prevents skin breakdown from a simple face mask by reducing friction and pressure on the face. Repositioning q2h (A) helps but isn't enough alone. Barrier cream (B) is for moisture, not pressure. Intermittent removal (D) disrupts therapy. Padding, per skin integrity standards, is proactive.