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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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.
During a physical assessment, a client was diagnosed with increased temperature due to an increased basal metabolic rate (BMR). Which hormonal imbalances may the client have? Select all that apply.
- A. Cortisol
- B. Thyroid
- C. Estrogen
- D. Testosterone
Correct Answer: B
Rationale: Increased BMR with elevated temperature suggests thyroid (B) excess (hyperthyroidism), boosting metabolism. Cortisol (A) affects stress, not BMR primarily. Estrogen (C) and testosterone (D) influence other systems. B is correct. Rationale: Thyroid hormones (T3, T4) directly raise BMR and heat, a classic endocrine imbalance, per physiology, unlike other hormones with indirect effects.
The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis?
- A. Visual disturbances, including diplopia
- B. Ascending paralysis and loss of motor function
- C. Cogwheel rigidity and loss of coordination
- D. Progressive weakness that is worse at the day's end
Correct Answer: D
Rationale: Progressive weakness worse at day's end (fatigue) is classic in myasthenia gravis, due to acetylcholine receptor issues diplopia occurs but isn't primary, ascending paralysis fits Guillain-Barré, and rigidity is Parkinson's. Nurses assess this, aiding diagnosis, key for neuromuscular care.
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 patient is characterized with a #16 indwelling urinary (Foley) catheter to determine if:
- A. Trauma has occurred
- B. His 24-hour output is adequate
- C. He has a urinary tract infection
- D. Residual urine remains in the bladder after voiding
Correct Answer: B
Rationale: A Foley catheter monitors 24-hour urine output for adequacy.