Nokea
The NICU nurse prepares for the arrival of the newborn. Which of the following PRIORITY item should be placed at the newborn's bedside? A _____________.
- A. Specific gravity urinometer
- B. Rectal thermometer
- C. Blood pressure cuff
- D. Bottle of sterile normal saline
Correct Answer: C
Rationale: The priority item that should be placed at the newborn's bedside is a blood pressure cuff. Monitoring the newborn's blood pressure is crucial in the NICU, as it helps assess the baby's cardiovascular function and overall well-being. Blood pressure changes can be an early indication of potential health issues, so having a blood pressure cuff readily available allows for timely monitoring and intervention if necessary. The other items listed (specific gravity urinometer, rectal thermometer, bottle of sterile normal saline) are also important in neonatal care, but monitoring blood pressure takes precedence in this scenario.
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Which nursing intervention constitutes false imprisonment?
- A. A client is hospitalized as an involuntary admission and attempts to leave the unit. The nurse calls the security team per hospital protocol. They prevent the client from leaving.
- B. A psychotic client is admitted as an involuntary client and runs out of the psychiatric unit. The nurse runs after the client and succeeds in talking the client into returning to the unit.
- C. The client has been "pesky," seeking the attention of nurses in the nurses' station much of the day.
- D. The client is confused, combative, and insists that no one can stop him from leaving. The nurse restrains the client without a physician's order, then seeks the order.
Correct Answer: D
Rationale: False imprisonment occurs when a client is physically restrained or confined without legal justification. In this scenario, the nurse restraining the confused and combative client without a physician's order constitutes false imprisonment. Restraints should only be used when necessary to ensure the safety of the client or others, and a physician's order is required to authorize their use. In this case, the nurse acted without proper authorization, making it a violation of the client's rights and false imprisonment. It is essential to follow proper protocols and obtain necessary orders before restraining a client.
A patient presents with a pruritic, annular rash with fine scaling and central clearing, affecting the trunk and proximal extremities. The patient reports recent exposure to a new soap and laundry detergent. Which of the following conditions is most likely responsible for this presentation?
- A. Tinea corporis (ringworm)
- B. Nummular eczema
- C. Pityriasis rosea
- D. Lichen planus
Correct Answer: B
Rationale: The presentation described is consistent with nummular eczema, also known as discoid eczema. Nummular eczema typically presents as circular or oval-shaped patches of eczematous rash with fine scaling and central clearing. It is often pruritic and can be triggered by exposure to irritants such as new soaps or laundry detergents. The distribution on the trunk and proximal extremities is also typical for nummular eczema. Tinea corporis (ringworm) would present with a more raised, scaly, and well-defined border with central clearing. Pityriasis rosea presents with a herald patch followed by smaller oval or round lesions in a "Christmas tree" distribution. Lichen planus would present with polygonal, purplish, flat-topped papules typically located on flexural surfaces and extremities.
Nurses agree to be advocates for their patients. Practice of advocacy calls for the nurse to:
- A. Seek out the nursing supervisor in conflicting situations
- B. Work to understand the law as it applies to the client's clinical condition.
- C. Assess the client's point of view and prepare to articulate this point of view.
- D. Document all clinical changes in the medical record in a timely manner.
Correct Answer: C
Rationale: The practice of advocacy in nursing involves assessing the client's point of view and preparing to articulate this viewpoint. Advocacy requires that nurses actively listen to their patients, understand their perspectives, and ensure that their needs and wishes are communicated effectively within the healthcare team. By advocating for the client's point of view, nurses can help empower their patients to make informed decisions about their care and ensure that their best interests are always prioritized.
In her capacity to teach, the nurse describes the changes of the uterus after childbirth to return to a nonpregnant state as _____
- A. catabolism
- B. subinvolution
- C. contraction of muscle fibers
- D. Involution
Correct Answer: D
Rationale: Involution refers to the process of the uterus returning to its nonpregnant state after childbirth. During pregnancy, the uterus undergoes significant changes and enlarges to accommodate the growing fetus. After childbirth, the uterus begins to contract, leading to a decrease in its size and a return to its pre-pregnant state. This process involves the shedding of the excess endometrial tissue and the reduction of the size of the uterine muscle fibers. It is a normal and essential process for postpartum recovery. Failure of the uterus to undergo proper involution is known as subinvolution, which can lead to complications such as postpartum hemorrhage.
Which of the following is a common clinical manifestation of osteoarthritis in the hip joint?
- A. Baker's cyst
- B. Heberden's nodes
- C. Trendelenburg gait
- D. Swan-neck deformity
Correct Answer: C
Rationale: Osteoarthritis in the hip joint can lead to weakness or dysfunction in the hip abductor muscles, causing a Trendelenburg gait. This gait abnormality is characterized by a dropping of the pelvis on the opposite side of the affected hip during weight-bearing on the affected leg. It is a common clinical manifestation of hip osteoarthritis due to the muscle weakness and altered mechanics in the hip joint. Baker's cyst is associated with knee osteoarthritis, Heberden's nodes are commonly seen in osteoarthritis of the fingers, and Swan-neck deformity is typically seen in rheumatoid arthritis, not osteoarthritis.