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The nurse informed the doctor that Mr. Gary does not want a certain procedure. This is an example of?
- A. Advocacy
- B. Fidelity
- C. Veracity
- D. Justice
Correct Answer: A
Rationale: Informing the doctor of Mr. Gary's refusal is advocacy (A) upholding his rights, per nursing. Fidelity (B) promises, veracity (C) truth, justice (D) fairness not refusal-based. A supports autonomy, making it correct.
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When teaching a client with a new diagnosis of heart failure about dietary management, which of the following statements should the nurse include?
- A. Increase your intake of sodium-rich foods.
- B. Decrease your intake of sodium-rich foods.
- C. Avoid foods that contain lactose.
- D. Increase your intake of dairy products.
Correct Answer: B
Rationale: The correct answer is to decrease the intake of sodium-rich foods. Sodium restriction is crucial in managing heart failure as it helps to reduce fluid retention and alleviate symptoms. Excessive sodium intake can lead to fluid buildup in the body, worsening heart failure. Therefore, advising the client to decrease sodium-rich foods is essential for their overall health and management of the condition. Choices A, C, and D are incorrect. Increasing intake of sodium-rich foods (Choice A) would worsen fluid retention and heart failure symptoms. Avoiding foods that contain lactose (Choice C) is not directly related to heart failure management through sodium restriction. Increasing intake of dairy products (Choice D) may not be suitable for all heart failure patients, especially if they need to limit saturated fats or cholesterol in their diet.
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.
The nurse is planning care for a client with a chronic illness. Which intervention reflects tertiary prevention?
- A. Screening the client for depression
- B. Teaching the client strategies for living with the illness
- C. Encouraging the client to receive an annual flu vaccine
- D. Educating the client about preventing transmission of illness
Correct Answer: B
Rationale: Tertiary prevention optimizes life with a chronic illness, reducing its impact post-diagnosis. Teaching strategies for living with it like pacing activities for arthritis helps the client adapt, minimizing disability and enhancing function, a nursing priority. Screening for depression is secondary, detecting new issues, not managing the existing one. An annual flu vaccine is primary, preventing unrelated illness, not addressing the chronic condition's effects. Educating about transmission fits infectious cases, not all chronic ones. This intervention tailored coping reflects nursing's role in rehabilitation, ensuring clients thrive despite limits. For instance, teaching a heart failure client fluid management cuts readmissions, aligning with tertiary care's focus on sustaining quality of life through practical, illness-specific support.
The most common psychogenic disorder among elderly persons is:
- A. Depression
- B. Sleep disturbances (such as bizarre dreams)
- C. Inability to concentrate
- D. Decreased appetite
Correct Answer: A
Rationale: Depression is the most prevalent psychogenic issue in older adults.
The nurse is assessing the client for abdominal distention, which of the following technique should be performed by the nurse?
- A. Inspection alone is sufficient
- B. Inspection and Palpation
- C. Inspection and Percussion
- D. Inspection, Palpation and Percussion
Correct Answer: C
Rationale: Abdominal distention needs inspection (e.g., bloating) and percussion (e.g., tympany for gas) unlike inspection alone or palpation (tenderness). Nurses use e.g., tap for cause, per assessment.