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The nurse is caring for a child with a head injury. Place the following assessments in order of priority, starting with the nursing assessment the nurse should perform first.
- A. Vital signs.
- B. Decreased urine output.
- C. Level of consciousness.
- D. Motor strength.
Correct Answer: C,A,D,B
Rationale: Level of consciousness is the priority to assess neurological status, followed by vital signs for stability, motor strength for deficits, and urine output for systemic effects.
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A client with a fracture is placed in skeletal traction. What is the nurse's priority assessment?
- A. Skin integrity at pin sites.
- B. Range of motion in the affected limb.
- C. Pain level during movement.
- D. Muscle strength in the unaffected limb.
Correct Answer: A
Rationale: Monitoring skin integrity at pin sites is critical to detect infection or tissue breakdown in skeletal traction.
The nurse is caring for a client with a new colostomy. Which statement by the client indicates a need for further teaching?
- A. I should change the pouch every 5 to 7 days.'
- B. I can eat high-fiber foods to promote regular bowel movements.'
- C. I should avoid gas-forming foods like beans.'
- D. I need to drink 2 to 3 liters of fluid daily.'
Correct Answer: B
Rationale: High-fiber foods may cause blockages in a new colostomy. The client should start with a low-residue diet and gradually introduce fiber, indicating a need for further teaching.
You are the supervising nurse in a physical rehabilitation center that has the philosophy that clients have the need to cope with their disabilities and its limitations are the result of a discrepancy between the client's abilities and the limitations of the physical and social environment within which the client lives. Which model of disability is this philosophy based on?
- A. Orem's Self Care Model
- B. Nagis Model
- C. A cognitive model of disability
- D. A biomedical model of disability
Correct Answer: C
Rationale: This philosophy aligns with the cognitive model of disability, which emphasizes the interaction between an individual's abilities and environmental barriers, focusing on adaptation and coping strategies.
Which of the following should the nurse teach a client with generalized anxiety disorder to help the client cope with anxiety?
- A. Cognitive and behavioral strategies.
- B. Issue avoidance and denial of problems.
- C. Rest and sleep.
- D. Withdrawal from role expectations and role relationships.
Correct Answer: A
Rationale: Cognitive and behavioral strategies, such as relaxation techniques, help clients manage anxiety effectively.
The nurse is caring for a client with a history of burns. Which of the following complications should the nurse monitor for? Select all that apply.
- A. Sepsis.
- B. Hypovolemia.
- C. Hyperkalemia.
- D. Respiratory distress.
- E. Hypoglycemia.
Correct Answer: A, B, C, D
Rationale: Burns can cause sepsis (infection), hypovolemia (fluid loss), hyperkalemia (tissue damage), and respiratory distress (inhalation injury).