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The nurse is aware that this is considered as the master gland of the body
- A. Hypothalamus
- B. Pituitary gland
- C. Thyroid gland
- D. Pineal gland
Correct Answer: B
Rationale: The pituitary gland master gland e.g., regulates thyroid, adrenals via hormones. Hypothalamus controls it, thyroid/pineal have specific roles. Nurses know e.g., endocrine for systemic effects, per physiology.
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What is nurse's primary critical observation when performing an assessment for determining an Apgar score?
- A. Heart rate
- B. Respiratory rate
- C. Presence of meconium
- D. Evaluation of Moro reflex
Correct Answer: A
Rationale: Apgar score assesses newborn vitality at 1 and 5 minutes post-birth across five criteria: heart rate, respiration, muscle tone, reflex, color. Heart rate (choice A) is primary; absent (<60 bpm = 0, <100 = 1, >100 = 2) dictates immediate resuscitation, making it the most critical. Respiratory rate (choice B) follows, but weak/absent breathing often ties to heart rate. Meconium (choice C) isn't scored directly, though it flags distress. Moro reflex (choice D) tests tone/reflex, secondary to vitals. A is correct, as heart rate drives initial intervention. Nurses prioritize it, ensuring rapid response to stabilize the infant.
A client is scheduled for a computed tomography (CT) of the brain with contrast. When reviewing the client's medical record, what significant finding should the nurse report to the primary healthcare provider before the diagnostic procedure?
- A. The client takes metformin daily.
- B. The client has not been nothing by mouth (NPO).
- C. The client reports an allergy to gadolinium.
- D. The client was not prescribed a bowel prep.
Correct Answer: A
Rationale: Metformin (A) is significant before a CT with contrast due to lactic acidosis risk if renal function declines from contrast dye. NPO status (B) isn't critical for brain CT. Gadolinium (C) is MRI-related, not CT. Bowel prep (D) is irrelevant. A is correct. Rationale: Contrast can impair kidneys, exacerbating metformin toxicity, requiring provider adjustment, per radiology safety protocols.
When providing holistic care to a client, the nurse recognizes that which behaviors are necessary?
- A. Understand and respect each person's definition of health
- B. Understand and respect each person's responses to illness
- C. Focus on a standard definition of health and beliefs
- D. Instruct the client that health is an inactive process
Correct Answer: A
Rationale: Holistic care in nursing embraces the whole person mind, body, spirit requiring tailored approaches. Understanding and respecting each person's definition of health acknowledges their unique values, like viewing wellness as independence or spiritual peace, shaping care plans. Respecting responses to illness honors individual coping like stoicism or seeking support fostering trust. A standard health definition ignores this diversity, risking alienation, while calling health inactive contradicts its dynamic nature people actively pursue it. Holistic nursing uses models like the wellness wheel to integrate dimensions, ensuring care fits the client, not a mold. This flexibility enhances engagement, as when a nurse adapts teaching for a client valuing herbal remedies, strengthening outcomes by aligning with personal beliefs and experiences.
Which intervention is important in preventing pressure ulcers in immobilized patients?
- A. Frequent repositioning
- B. Encouraging immobility
- C. Maintaining prolonged periods of immobility
- D. Applying tight dressings over bony prominences
Correct Answer: A
Rationale: Frequent repositioning prevents pressure ulcers in immobilized patients by relieving pressure on skin over bones, boosting circulation, and reducing tissue breakdown risk. Sustaining or promoting immobility heightens this risk, as does tight dressings that add pressure and impair blood flow. Nurses implement this intervention shifting positions every two hours, for instance to protect skin integrity, a fundamental strategy in caring for those unable to move independently, prioritizing prevention over reactive treatment.
A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits. What should the nurse do first?
- A. Call the physician
- B. Remedicate the patient
- C. Observe the emesis
- D. Explain to the patient that she can do nothing to help him
Correct Answer: C
Rationale: Observing the emesis checks for medication remnants, guiding next steps.