Nokea
Signs such as using tissues to doorknobs develop because the patient is ________.
- A. unconsciously controlling unacceptable impulses or feelings
- B. Listening to voices that tell her that doorknobs are unclean
- C. consciously using this method of punishing herself
- D. fulfilling a need to punish others procedure by carrying out annoying
Correct Answer: A
Rationale: Signs such as using tissues to doorknobs suggest that the patient is unconsciously controlling unacceptable impulses or feelings. This behavior falls under the category of defense mechanisms, specifically displacement, where the individual redirects their emotions from a threatening target to a safer one. In this case, the patient may be experiencing anxiety or fear related to contamination or germs, leading them to use tissues to avoid touching doorknobs directly. It is a way for the patient to manage their underlying emotions, albeit unconsciously, through this compulsive behavior.
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A patient with a spinal cord injury at the level of T6 presents with hypotension, bradycardia, and diaphoresis following a sudden change in position from supine to sitting. Which condition is the patient most likely experiencing?
- A. Autonomic dysreflexia
- B. Neurogenic shock
- C. Spinal shock
- D. Orthostatic hypotension
Correct Answer: A
Rationale: The patient is most likely experiencing autonomic dysreflexia. Autonomic dysreflexia is a potentially life-threatening condition that can occur in individuals with spinal cord injuries at the level of T6 or above. It is characterized by a sudden onset of severe hypertension, bradycardia, diaphoresis, flushing, and headache in response to a noxious stimulus below the level of injury. The sudden change in position from supine to sitting likely triggered autonomic dysreflexia in this patient.
The false statement about physiologic jaundice in the statements below is _____
- A. Caused by impairment in the removal of bilirubin deficiency in the production of glucuronide transferase.
- B. Begins to decrease by the 6th or 7th day.
- C. Is visible in skin and sclera.
- D. Begins after 48 hours of 1ife.
Correct Answer: A
Rationale: Physiologic jaundice in newborns is a common and typically benign condition caused by the immaturity of the newborn's liver. The correct statement about physiologic jaundice is that it occurs due to an imbalance between the production and elimination of bilirubin. In contrast, Option A is the false statement because it incorrectly states that physiologic jaundice is caused by impairment in the removal of bilirubin deficiency in the production of glucuronide transferase. This statement is inaccurate as physiologic jaundice results from the immature liver's reduced ability to conjugate bilirubin.
A confused client who fell out of bed because side rails were not used is an example of which type of liability?
- A. Felony
- B. Battery
- C. Assault
- D. Negligence
Correct Answer: D
Rationale: Negligence is the failure to take proper care in doing something, which results in harm or injury to someone else. In this scenario, the client falling out of bed because side rails were not used indicates a lack of proper care or attention by the staff or caregiver responsible for the client. It shows a failure to protect the client from harm, which aligns with the definition of negligence. This situation does not fit the definitions of a felony, battery, or assault.
Nurse Edna admits a patient from the ER to the medical unit. The patient is very restless with IV lines and a urinary catheter. She was put to bed and the nurse applied a body restraint without the doctor's order. Nurse Edna's action can be liable for _____.
- A. invasion of privacy
- B. assault
- C. battery
- D. neglect
Correct Answer: C
Rationale: Battery occurs when there is an intentional harmful or offensive contact with a person without their consent. In this scenario, Nurse Edna applied a body restraint to the patient without the doctor's order, which constitutes unauthorized physical contact. The patient did not give consent for the restraint, and Nurse Edna's action could be considered battery. It is important for healthcare providers to obtain proper authorization before using any form of physical restraint on a patient to avoid legal implications such as battery.
A nurse is preparing to administer a nasogastric (NG) tube feeding for a patient. What action should the nurse prioritize before initiating tube feeding?
- A. Verifying the NG tube placement by auscultating for bowel sounds
- B. Securing the NG tube to prevent dislodgement during feeding
- C. Checking the patency of the NG tube by aspirating gastric contents
- D. Elevating the head of the bed to a semi-Fowler's position
Correct Answer: C
Rationale: The nurse should prioritize checking the patency of the NG tube by aspirating gastric contents before initiating tube feeding. This is important to ensure that the NG tube is in the correct position and that it is functioning properly. By aspirating gastric contents, the nurse can confirm that the tube is in the stomach and not in the lungs or surrounding tissues. If no gastric contents are obtained upon aspiration, it may indicate that the tube is not properly placed or may be occluded, which would require further assessment and intervention before proceeding with tube feeding. Checking the patency of the NG tube is a crucial step in ensuring the safety and effectiveness of enteral nutrition delivery.