Nokea
The nurse encouraged Mr. Gary to make his own care decisions. This is an example of?
- A. Empowerment
- B. Advocacy
- C. Coping
- D. Quality improvement
Correct Answer: A
Rationale: Encouraging care decisions is empowerment (A) control to patient, per definition. Advocacy (B) supports, coping (C) manages, QI (D) enhances not decision-specific. A fits patient autonomy, making it correct.
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A client with a traumatic brain injury has an intracranial pressure (ICP) of $15 \mathrm{mmHg}$ and a mean arterial pressure (MAP) of $90 \mathrm{mmHg}$. What is the cerebral perfusion pressure (CPP)?
- A. 65 mmHg
- B. 75 mmHg
- C. 85 mmHg
- D. 95 mmHg
Correct Answer: B
Rationale: CPP = MAP - ICP; 90 - 15 = 75 mmHg (B). Other options (A, C, D) miscalculate. B is correct. Rationale: CPP of 75 mmHg is within normal (60-100), ensuring brain perfusion, per neurocritical care, critical for TBI outcomes.
Which of the following statement is TRUE about illness behavior?
- A. How people react when they are sick
- B. How people prevent illness
- C. How people treat illness
- D. All of the above
Correct Answer: A
Rationale: Illness behavior is how people react when sick (A), per sociology e.g., seeking care. Prevention (B) and treatment (C) are separate, not all (D). A truly defines illness response, making it correct.
Which of the following statement best describe patient advocacy?
- A. Ignoring patient needs
- B. Supporting patient rights
- C. A routine task
- D. A medical treatment
Correct Answer: B
Rationale: Patient advocacy is supporting patient rights (B), per nursing e.g., voicing wishes. Not ignoring (A), not routine (C), not treatment (D) rights-focused. B best defines advocacy's protective role, making it correct.
Which of the following statement is TRUE about objective data?
- A. Reported by the client
- B. Observed by the nurse
- C. Always subjective
- D. All of the above
Correct Answer: B
Rationale: Objective data is observed by the nurse (B), per assessment e.g., rash. Not reported (A), not subjective (C), not all (D) measurable. B truly defines objective's basis, making it correct.
The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?
- A. Suctioning is required frequently.
- B. Aspiration of gastric contents occurs when suctioning.
- C. The client's skin and mucous membranes are light pink.
- D. Excessive secretions are suctioned from a tracheostomy.
Correct Answer: B
Rationale: Tracheoesophageal fistula (TEF), a rare tracheostomy complication, involves an abnormal connection between trachea and esophagus. Aspiration of gastric contents during suctioning (B) is a definitive sign, indicating esophageal leakage into the airway. Frequent suctioning (A) or excessive secretions (D) are nonspecific. Pink skin (C) reflects good oxygenation, not TEF. B is correct. Rationale: TEF allows gastric contents to enter the trachea, detected during suctioning, requiring urgent intervention like tube adjustment or surgery, distinct from routine secretion issues, per critical care nursing.