Nokea
The client is in stress because he was told by the physician he needs to undergo surgery for removal of tumor in his bladder. Which of the following are effects of sympatho-adrenomedullary response by the client? 1. Constipation 2. Urinary frequency 3. Hyperglycemia 4. Increased blood pressure
- A. 3,4
- B. 1,3,4
- C. 1,2,4
- D. 1,4
Correct Answer: A
Rationale: The sympatho-adrenomedullary response, part of the fight-or-flight reaction to stress (surgery news), releases catecholamines like epinephrine, causing hyperglycemia (3) and increased blood pressure (4). Hyperglycemia results from glycogenolysis to fuel energy needs. Blood pressure rises due to vasoconstriction and increased heart rate. Constipation (1) isn't immediate; stress slows digestion long-term. Urinary frequency (2) contradicts the response's fluid retention. Only 3 and 4 (A) match acute sympathetic activation, making it correct over broader or incorrect combinations.
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What is the purpose of utilizing proper positioning techniques for patients?
- A. To maintain patient comfort
- B. To promote social interaction
- C. To facilitate ambulation
- D. To improve coordination
Correct Answer: A
Rationale: Proper positioning techniques aim to maintain patient comfort by reducing pressure points, aligning the body, and preventing pain or discomfort during rest or treatment. This focus enhances patient well-being, crucial for recovery and satisfaction in care settings. Encouraging social engagement, aiding walking, or enhancing coordination, while valuable, aren't the core objectives of positioning those require distinct interventions like group activities or physical therapy. Comfort underpins healing, as unrelieved pressure or misalignment can lead to complications like ulcers or muscle strain. Nurses prioritize this to support physiological stability, ensuring patients feel at ease, which indirectly supports broader therapeutic goals without being the primary intent.
A recently licensed registered nurse is preparing to enter practice in an acute care facility and wants to practice within the guidelines of that state. When preparing to research the state nurse practice act, what information is important to obtain?
- A. Content for the NCLEX
- B. The members of the state board of nursing
- C. Definition of legal scope of nursing practice
- D. Definition of important terms related to nursing
Correct Answer: C
Rationale: State nurse practice acts are critical legal frameworks that govern nursing practice within each jurisdiction, ensuring safe and competent care. For a newly licensed registered nurse, understanding the definition of the legal scope of nursing practice is essential, as it outlines what nurses are authorized to do, including specific tasks, responsibilities, and limitations in an acute care setting. Equally important is the definition of key terms related to nursing, which clarifies concepts like licensure, delegation, and accountability, helping the nurse navigate their role legally and ethically. While the NCLEX content is vital for licensure, it's a national exam and not state-specific. Knowing the members of the state board of nursing might be useful for context but isn't directly relevant to daily practice guidelines. The nurse practice act provides the foundational rules for compliance, protecting both the nurse and the public by setting clear professional boundaries and expectations.
A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:
- A. Will cause dark staining of the surrounding skin
- B. Produces a cooling sensation when applied
- C. Can alter the function of the thyroid
- D. Produces a burning sensation when applied
Correct Answer: D
Rationale: Sulfamylon cream causes a burning sensation on application to burns, a known effect due to its penetration into damaged tissue, requiring pain management a pediatric care priority. Staining, cooling, or thyroid impact aren't typical. Nurses prepare for this, using analgesics to ease discomfort, supporting healing in young clients.
A group of nurses is participating in a community health fair and is engaged in primary prevention activities. Which activities would these nurses be leading?
- A. Family planning services
- B. Accident prevention education
- C. Heart-healthy nutrition services
- D. Skin cancer screening
Correct Answer: A
Rationale: Primary prevention aims to promote health and stop disease before it starts, a key nursing role at health fairs. Family planning services educate on contraception, preventing unintended pregnancies a proactive health step. Accident prevention education, like teaching helmet use, averts injuries, targeting safety before incidents. Heart-healthy nutrition services promote diets reducing cardiovascular risk, fostering wellness pre-disease. Skin cancer screening, though vital, is secondary prevention, detecting issues early, not preventing onset. Rehabilitation for back pain is tertiary, managing existing conditions. These primary activities planning, safety, nutrition empower communities with knowledge and habits to sidestep illness, aligning with nursing's preventive focus, leveraging education to build health resilience before crises emerge.
A client has a new diagnosis of osteoarthritis and is being taught about dietary management. Which of the following statements should be included in the teaching?
- A. Increase your intake of calcium-rich foods.
- B. Avoid foods that are high in potassium.
- C. Increase your intake of vitamin D-rich foods.
- D. Avoid foods that are high in sodium.
Correct Answer: C
Rationale: The correct statement to include in the teaching is to increase the intake of vitamin D-rich foods. Vitamin D helps improve calcium absorption, which is beneficial for bone health and may help alleviate symptoms of osteoarthritis. Option A is incorrect because while calcium is important for bone health, the focus should be on vitamin D for calcium absorption. Option B is incorrect as potassium is generally not restricted in osteoarthritis. Option D is also incorrect as sodium restriction is more relevant for conditions like hypertension or heart failure, not specifically for osteoarthritis.