Nokea
Rehabilitation utilises two types of rehabilitation interventions. The goal of the intervention support is to
- A. Maintaining existing abilities
- B. Restoring function
- C. Preventing deterioration and further disability
- D. Maintaining existing abilities while preventing new or further disabilities
Correct Answer: D
Rationale: Rehab's dual play hold steady, fend off worse blends maintenance and prevention, a chronic balance. Nurses aim here, a full guard.
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You measure the abdominal circumference and the hip circumference of a male patient with hypertension, overweight and recently-diagnosed type 2 diabetes mellitus. Question: Which values are most likely to be found in this patient?
- A. Abdomen: 78 cm, hip: 78 cm
- B. Abdomen: 78 cm, hip: 86 cm
- C. Abdomen: 102 cm, hip: 90 cm
- D. Abdomen: 90 cm, hip: 102 cm
Correct Answer: C
Rationale: Type 2, hypertension, overweight belly bulges past hips, 102 cm to 90 cm fits metabolic syndrome's apple shape, not slim or reverse. Nurses measure this, a chronic girth clue.
A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?
- A. Assessing the IV site every hour
- B. Educating the client on side effects
- C. Monitoring the client for nausea
- D. Providing warm packs for comfort
Correct Answer: A
Rationale: Chemotherapy drugs administered via peripheral IV can be vesicants, meaning they can cause severe tissue damage if they leak (extravasate) into surrounding tissues. Peripheral lines are more prone to this than central lines due to smaller vein size and less secure placement. Assessing the IV site hourly or per facility policy is the most important action to prevent extravasation, ensuring the line remains patent and no swelling, redness, or pain develops. Early detection allows prompt intervention, like stopping the infusion, to minimize harm. Educating about side effects and monitoring for nausea are key aspects of care but address systemic effects, not the immediate risk of local tissue injury. Warm packs might soothe discomfort but could worsen damage if extravasation occurs. Prioritizing IV site assessment reflects the nurse's role in safety and prevention, critical in oncology where chemotherapy's potency demands vigilant monitoring to protect the client from serious complications.
The emergency management of the patient with acute asthma does not include:
- A. Performing a rapid physical examination
- B. Performing spirometry or peak flow on arrival
- C. Giving oxygen and short acting bronchodilator
- D. Close monitoring to determine efficacy of treatment and improvement or deterioration
Correct Answer: B
Rationale: Acute asthma's rush exam, O2, bronchodilators, tight watch saves breath fast. Spirometry's a no too tough mid-wheeze, delays care. Nurses skip it, a chronic flare's urgent dodge.
About special considerations in the management of hypertension in older patients, which of the following is the correct answer?
- A. Systolic hypertension - DBP should be <70 mmHg
- B. Dementia - Target SBP should not be <150/90 mmHg
- C. Care home residents - SBP <130 mmHg
- D. Frailty - Target BP not <140/90 mmHg
Correct Answer: D
Rationale: Frail elders BP >140/90 guards perfusion; systolic, dementia, care home tweaks misfire. Nurses ease this chronic frail line.
Which nursing action should be included in the plan of care for a client returning to the surgical unit following a left modified radical mastectomy with dissection of axillary lymph nodes?
- A. Obtain permanent breast prosthesis before the patient is discharged from the hospital
- B. Teach the patient to use the ordered patient-controlled analgesia (PCA) every 10 minutes
- C. Place a pink bracelet on the client warning against venipunctures or blood pressures in the left arm
- D. Insist that the patient examine the surgical incision when the initial dressings are removed
Correct Answer: C
Rationale: Mastectomy with axillary dissection risks lymphedema a pink bracelet flags the left arm, barring venipuncture or BP cuffs to prevent swelling, a priority in post-op care. Prosthesis comes later, post-healing. PCA teaching avoids rigid timing PRN's key. Forcing incision checks risks distress, not healing. Nurses lock in this bracelet, safeguarding lymph flow, a must-do in this surgical aftermath to dodge chronic arm woes.