Nokea
The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis?
- A. Visual disturbances, including diplopia
- B. Ascending paralysis and loss of motor function
- C. Cogwheel rigidity and loss of coordination
- D. Progressive weakness that is worse at the day's end
Correct Answer: D
Rationale: Progressive weakness worse at day's end (fatigue) is classic in myasthenia gravis, due to acetylcholine receptor issues diplopia occurs but isn't primary, ascending paralysis fits Guillain-Barré, and rigidity is Parkinson's. Nurses assess this, aiding diagnosis, key for neuromuscular care.
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The physician has ordered a 2-gram sodium diet for a client with hypertension. Which food should be limited due to its sodium content?
- A. Potato chips
- B. Baked chicken
- C. Steamed broccoli
- D. Fresh apple
Correct Answer: A
Rationale: Potato chips are high in sodium often 120-180 mg per ounce exceeding a 2-gram (2000 mg) daily limit for hypertension, necessitating restriction to control blood pressure. Baked chicken, steamed broccoli, and fresh apples have minimal natural sodium, fitting the diet. Nurses educate clients on hidden sodium in processed snacks, promoting fresh alternatives to reduce cardiovascular strain, aligning with therapeutic goals for long-term health management.
The nurse is preparing a client with gout for discharge. Which dietary selection reflects an understanding of the client's condition?
- A. Broiled chicken, rice, and iced tea
- B. Sardines, lima beans, and red wine
- C. Hamburger, fries, and a milkshake
- D. Shrimp, spinach, and beer
Correct Answer: A
Rationale: Broiled chicken, rice, and iced tea suit gout, avoiding purine-rich foods (sardines, shrimp) or alcohol (wine, beer) that raise uric acid lima beans and spinach also contribute less but aren't ideal. Nurses teach this, reducing flare-ups, supporting joint health and client compliance.
Which of the following statement is TRUE about safety in health care?
- A. Errors are unavoidable
- B. Focuses on preventing harm
- C. Only applies to surgery
- D. All of the above
Correct Answer: B
Rationale: Safety focuses on preventing harm (B), per standards e.g., protocols reduce risks. Errors can be minimized (A), not surgery-only (C), not all (D) broad scope. B truly defines safety's priority, making it correct.
The nurse is caring for an infant with developmental dysplasia of the hip. The nurse should expect to:
- A. Prepare the infant for application of a body cast
- B. Teach the mother to keep the infant in the prone position
- C. Explain that surgery will be necessary within the first 3 months
- D. Tell the mother that the condition will correct itself without treatment
Correct Answer: A
Rationale: For developmental dysplasia of the hip (DDH), a body cast (spica) is often applied to maintain hip alignment, a common intervention post-reduction in infants, guided by orthopedics. Prone positioning, early surgery, or spontaneous correction aren't standard treatment stabilizes the joint. Nurses prepare families for this, explaining its role in preventing long-term disability, ensuring compliance and comfort.
Nurse Aida has seen her patient, Roger for the first time. She establish a contract about the frequency of meeting and introduce to Roger the expected termination. She started taking baseline assessment and set interventions and outcomes. On what phase of NPR Does Nurse Aida and Roger belong?
- A. Pre Orientation
- B. Orientation
- C. Working
- D. Termination
Correct Answer: B
Rationale: Nurse Aida and Roger are in the Orientation phase (B). This stage involves the first meeting, establishing a contract (meeting frequency, termination expectations), and initial assessments to set goals. Pre-Orientation (A) is before contact, reviewing records. Working (C) focuses on implementing plans, and Termination (D) ends the relationship. Orientation, per Peplau, sets the foundation with trust and planning, matching Aida's actions, making B correct.