Nokea
The nurse is assessing a client with suspected Bell's palsy. Which finding supports this diagnosis?
- A. Unilateral facial weakness
- B. Bilateral hand tremors
- C. Severe headache
- D. Neck stiffness
Correct Answer: A
Rationale: Unilateral facial weakness is the primary symptom of Bell's palsy, caused by facial nerve inflammation or compression.
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The nurse receives a client from the postanesthesia care unit who has had skeletal traction applied in the operating room. The nurse should take immediate action to correct which problem with the traction setup when it is noted?
- A. Knots are secured tightly.
- B. There are weights at both ends of the bed.
- C. Weights are resting against the foot of the bed.
- D. Pin site is exposed to air without any dressing.
Correct Answer: C
Rationale: The traction setup is checked to ensure that weights are hanging freely from the ropes and knots are tied securely. The weights should not be resting on the bed. Countertraction is commonly supplied by the client's body weight or by weights pulling in the opposite direction. Therefore, there can be weights at both ends of the bed. Pin-site care varies but usually includes regularly removing exudate with half-strength hydrogen peroxide, rinsing pin sites with sterile saline, and drying the area with sterile gauze; the pin site is left open to air. If any problems are noted, they should be fixed immediately.
You are asked by your supervisor to take photographs of the residents and their family members who are attending a holiday dinner and celebration at your long term care facility. What should you do?
- A. Take the photographs because these photographs are part of the holiday tradition at this facility
- B. Take the photographs because all of the residents are properly attired and in a dignified condition
- C. Refuse to take the photographs unless you have the consent of all to do so
- D. Refuse to take the photographs because this is not part of the nurse's role
Correct Answer: C
Rationale: Taking photographs without the explicit consent of all residents and family members violates their privacy rights under HIPAA . Consent must be obtained to ensure compliance with privacy regulations.
A client with chronic renal failure is receiving hemodialysis. Which dietary restriction should the nurse emphasize?
- A. Low-protein diet.
- B. High-sodium diet.
- C. Low-potassium diet.
- D. High-calcium diet.
Correct Answer: C
Rationale: A low-potassium diet is critical in chronic renal failure to prevent hyperkalemia, which can cause cardiac complications.
You are caring for a group of clients who are adversely affected with phobias. Which form of group therapy will you most likely employ to treat these clients?
- A. Cognitive psychotherapy
- B. Behavioral psychotherapy
- C. Cognitive behavioral psychotherapy
- D. Psychoanalysis
Correct Answer: C
Rationale: Cognitive behavioral psychotherapy (CBT) is the most effective treatment for phobias, as it combines cognitive restructuring with behavioral techniques like exposure therapy to address irrational fears.
The nurse fails to recognize that a client's vital signs have deteriorated over the past 4 hours after surgery. Later, the client requires emergency surgery. Which legal consequence does the nurse potentially face because of a failure to act?
- A. Tort
- B. Statutory law
- C. Common law
- D. Misdemeanor
Correct Answer: A
Rationale: The nurse's inaction is consistent with a tort offense because a tort is a wrongful act intentionally or unintentionally committed against a person or the person's property. Option 2 describes laws that are enacted by state, federal, or local governments. Option 3 describes case law that has evolved over time via precedents. Option 4 is an offense under criminal law.