Nokea
Place the phases or stages of the inflammatory response in the correct sequential order, do NOT include any phases that is NOT part of the inflammatory process. 1. The vascular phase 2. The prodromal phase 3. The incubation phase 4. The initial injury 5. The exudate phase 6. The convalescence phase
- A. 4,2,1
- B. 4,1,5
- C. 4,5,1
- D. 4,2,5
Correct Answer: B
Rationale: The inflammatory response includes the initial injury (4), followed by the vascular phase (1, vasodilation and increased permeability), and then the exudate phase (5, fluid and cell migration). Prodromal (2), incubation (3), and convalescence (6) are not part of the inflammatory process. Thus, B (4,1,5) is correct.
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You are working as a wound care nurse. You measure the size of a client's wound and it is 3 cm deep, 2 cm long and 4 cm wide. You would document the dimension of this wound as:
- A. 6 cm
- B. 12 cm
- C. 20 cm
- D. 24 cm
Correct Answer: B
Rationale: Wound dimensions are documented as length x width x depth (2 cm x 4 cm x 3 cm), but the total linear measurement is not typically summed. However, based on the options, 12 cm may reflect a misinterpretation; the correct documentation is the individual measurements.
When creating a program to decrease the primary cause of disability and death in children, which of the following is most effective for the community health nurse to do?
- A. Encourage state legislators to draft legislation to promote prenatal care.
- B. Recommend that the health department make immunizations available at no cost to all children.
- C. Teach health and safety practices to children and their parents.
- D. Have a nurse practitioner hired for each of the schools in the community.
Correct Answer: B
Rationale: Free immunizations address the leading cause of preventable childhood disability and death by ensuring widespread protection against infectious diseases.
Which of the following should first alert the nurse that a child is hemorrhaging after a tonsillectomy?
- A. Mouth breathing.
- B. Frequent swallowing.
- C. Requests for a drink.
- D. Increased pulse rate.
Correct Answer: B
Rationale: Frequent swallowing is the earliest sign of post-tonsillectomy hemorrhage, as the child swallows blood from the surgical site. Increased pulse rate may occur later.
The nurse is caring for a client with a diagnosis of peptic ulcer disease. When monitoring the client for possible gastrointestinal perforation, the nurse identifies the importance of what assessment data?
- A. Slow, strong pulses
- B. Increase in bowel sounds
- C. Positive guaiac stool tests
- D. Sudden, severe abdominal pain
Correct Answer: D
Rationale: Sudden, severe abdominal pain is a sign of perforation. When perforation occurs, the pulse will more likely be weak and rapid. The nurse may be unable to hear bowel sounds at all. Positive guaiac stool results indicate the presence of bleeding but are not necessarily indicative of perforation.
The nurse is obtaining a health history from a Mexican American adult. The nurse should interpret the findings by understanding that Mexican American culture most highly values:
- A. Children
- B. Materialism
- C. Firstborn sons
- D. The elderly
Correct Answer: A
Rationale: Mexican American culture often places high value on children, emphasizing family and intergenerational bonds. Materialism, firstborn sons, and the elderly are valued but not as universally central.