Nokea
The healthcare provider is assessing a client with acute pancreatitis. Which finding is most concerning?
- A. Pain radiating to the back
- B. Blood pressure of 95/60 mmHg
- C. Elevated serum amylase
- D. Absent bowel sounds
Correct Answer: B
Rationale: In acute pancreatitis, a low blood pressure of 95/60 mmHg is the most concerning finding as it may indicate hypovolemia or shock, which are critical conditions requiring immediate intervention. Pain radiating to the back is a common symptom of pancreatitis but is not as immediately life-threatening as hypotension. Elevated serum amylase levels and absent bowel sounds are typical findings in acute pancreatitis and may indicate pancreatic inflammation and gastrointestinal motility issues, respectively, but they are not as acutely concerning as hypotension.
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A nurse in a provider's office is collecting data from the caregiver of a 12-month-old infant who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. Learning has occurred in which of the following domains?
- A. Cognitive
- B. Affective
- C. Psychomotor
- D. Kinesthetic
Correct Answer: B
Rationale: The correct answer is B: Affective. The caregiver's decision to postpone toilet training indicates a change in feelings or attitudes, which falls under the affective domain of learning. The affective domain relates to emotions, values, and attitudes. In this scenario, the caregiver's willingness to delay toilet training due to new information reflects a shift in attitude impacted by the educational session provided by the nurse. Choices A, C, and D are incorrect. The cognitive (choice A) domain involves intellectual skills and knowledge, the psychomotor (choice C) domain involves physical skills, and kinesthetic (choice D) is often used interchangeably with the psychomotor domain, which focuses on physical movement and coordination.
A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff?
- A. Dandruff
- B. Alopecia
- C. Pediculosis
- D. Xerostomia
Correct Answer: A
Rationale: The correct term the nurse will use to report scaling of the scalp is 'Dandruff.' Dandruff is characterized by scaling of the scalp that is often accompanied by itching. Choice B, 'Alopecia,' refers to hair loss, not scaling. Choice C, 'Pediculosis,' is the infestation of lice, not scaling. Choice D, 'Xerostomia,' pertains to dry mouth, which is unrelated to the described symptom of scaling of the scalp.
A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?
- A. Diffuse expiratory wheezing
- B. Loose, productive cough
- C. No relief from inhaler
- D. Fever and chills
Correct Answer: A
Rationale: During an acute asthma attack, one of the expected assessments by the nurse would be diffuse expiratory wheezing. This occurs due to narrowed airways and increased airflow velocity. Choice B, a loose productive cough, is not typically associated with an asthma attack. Choice C, no relief from inhaler, may indicate ineffective treatment but is not a direct assessment finding related to the physical examination. Choice D, fever and chills, are not typical symptoms of an asthma attack and would not be expected findings during the initial assessment of an acute asthma attack.
A client tells the nurse, "I have to check with my partner and see if they think I am ready to go home." The nurse responds, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client?
- A. Pacing
- B. Reflecting
- C. Paraphrasing
- D. Restating
Correct Answer: B
Rationale: Reflecting is the correct answer as it involves echoing back the client's feelings and concerns, helping them explore their thoughts. In this scenario, the nurse mirrors the client's statement to encourage the client to delve deeper into their emotions. Pacing involves matching the rate and flow of communication, paraphrasing is restating in different words, and restating is repeating what the client said without adding new information. Therefore, choices A, C, and D are not the appropriate clarifying technique demonstrated in the situation described.
A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members?
- A. Charge nurse
- B. Registered nurse (RN)
- C. Practical nurse (PN)
- D. Assistive personnel (AP)
Correct Answer: B
Rationale: In this scenario, a client who has undergone thoracic surgery and is being admitted from the PACU requires a high level of nursing care. Registered nurses (RNs) have the education and training necessary to provide the complex care and monitoring needed for a post-thoracic surgery client. Charge nurses may oversee units but may not always be directly involved in providing bedside care. Practical nurses (PNs) have a different scope of practice compared to RNs and may not have the advanced skills needed for post-thoracic surgery care. Assistive personnel (AP) provide valuable support but do not have the qualifications to manage the care of a client following thoracic surgery.