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The nurse inserts an intravenous (IV) catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. Which type of implementation skill is the nurse using?
- A. Cognitive
- B. Interpersonal
- C. Psychomotor
- D. Judgmental
Correct Answer: C
Rationale: The correct answer is C: Psychomotor. The nurse is demonstrating psychomotor skills by inserting an IV catheter correctly. Psychomotor skills involve the ability to perform physical tasks effectively and efficiently. This skill requires coordination, dexterity, and precision. The other choices are incorrect because:
A: Cognitive skills involve thinking, analyzing, and problem-solving.
B: Interpersonal skills involve communication and interaction with others.
D: Judgmental skills involve critical thinking and decision-making.
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A brain abscess is a collection of pus within the substance of the brain and is caused by:
- A. Direct invasion of the brain
- B. Spread of infection by other organs
- C. Spread infection from nearby sites
- D. All of the above mechanisms
Correct Answer: D
Rationale: The correct answer is D because a brain abscess can be caused by direct invasion of the brain, spread of infection by other organs, and spread of infection from nearby sites. Direct invasion can occur from trauma or surgery, while infections from other organs like the lungs or heart can travel through the bloodstream to the brain. Infections from nearby sites such as the sinuses or ears can also spread to the brain. Therefore, all of these mechanisms can lead to the formation of a brain abscess. Choices A, B, and C alone do not encompass all the possible causes of a brain abscess, making D the correct comprehensive answer.
The nurse is reviewing information about a client and notes the following documentation: 'Client is confused.' The nurse recognizes this information is an example of what?
- A. Subjective data
- B. A data cue
- C. An inference
- D. Primary data
Correct Answer: C
Rationale: The correct answer is C: An inference. When the nurse documents that the client is confused, it is an interpretation or conclusion drawn from the observed behavior or symptoms. Inferences are based on subjective and objective data. Subjective data (choice A) is based on what the client states, while a data cue (choice B) is a piece of information that may lead to an inference but is not the actual interpretation. Primary data (choice D) refers to firsthand information obtained directly from the client, which is not the case here. In this scenario, the nurse is making an inference based on the observed confusion, making choice C the correct answer.
A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement Risk for falls?
- A. Keep all side rails down at all times.
- B. Encourage patient to remain in bed most of the shift.
- C. Place patient in room away from the nurses’ station if possible.
- D. Assist patient into and out of bed every 4 hours or as tolerated.
Correct Answer: D
Rationale: The correct answer is D. This intervention is appropriate because it addresses the patient's reduced muscle strength following a left-sided stroke and the risk for falling. Assisting the patient into and out of bed regularly helps prevent falls by ensuring safe mobility and reducing the likelihood of accidents. It promotes independence while also providing necessary support.
A: Keeping all side rails down at all times may increase the risk of falls as it removes a safety measure that can help prevent falls.
B: Encouraging the patient to remain in bed most of the shift can lead to deconditioning and muscle weakness, increasing the risk of falls.
C: Placing the patient in a room away from the nurses' station does not directly address the risk for falls and may hinder timely assistance in case of emergencies.
In summary, option D is the most appropriate intervention as it addresses the patient's needs, promotes safety, and supports mobility to prevent falls effectively.
Which of the ff vitamins does a client lack if there is a problem with the absorption of calcium?
- A. Vitamin A
- B. Vitamin B
- C. Vitamin C
- D. Vitamin D
Correct Answer: D
Rationale: The correct answer is D: Vitamin D. Vitamin D is essential for the absorption of calcium in the intestines. Without sufficient vitamin D, the body cannot effectively absorb calcium, leading to potential issues with calcium absorption. Vitamin A (choice A) is not directly involved in calcium absorption. Vitamin B (choice B) and Vitamin C (choice C) also do not play a significant role in calcium absorption. Therefore, the lack of Vitamin D is the most likely cause for problems with calcium absorption.
Mr Santos is placed on seizure precaution. Which of the following would be contraindicated?
- A. Obtain his oral temperature
- B. Allow him to wear his own clothing
- C. Encourage to perform his own personal
- D. Encourage him to be out of bed hygiene
Correct Answer: A
Rationale: The correct answer is A: Obtain his oral temperature. Seizure precautions typically include avoiding putting objects in the mouth to prevent injury during a seizure. Taking an oral temperature involves placing an object in the mouth, which could pose a risk if a seizure occurs. Choices B, C, and D are not contraindicated as they do not directly involve potential risks during a seizure. Allowing the patient to wear his own clothing, encouraging personal hygiene, and promoting mobility are safe practices that do not increase the risk of harm during a seizure.