Nokea
The nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?
- A. Reassess the client in 15 minutes.
- B. Administer the prescribed analgesic.
- C. Inform the nurse manager.
- D. Call the physician immediately.
Correct Answer: D
Rationale: The correct answer is D. Calling the physician immediately is crucial because a severe headache in a client with a cerebral aneurysm may indicate a rupture, a life-threatening emergency. The physician needs to be notified promptly for urgent intervention. Reassessing the client in 15 minutes (Choice A) may delay necessary action. Administering an analgesic (Choice B) without knowing the underlying cause of the headache could mask symptoms and delay appropriate treatment. Informing the nurse manager (Choice C) is not the priority; direct communication with the physician for immediate medical intervention is essential in this situation.
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Scoliosis can be classified as structural or functional. Which one of the following is NOT a characteristic of structural scoliosis?
- A. Most cases are idiopathic
- B. It is reversible
- C. Subtype of structural scoliosis includes idiopathic
- D. Subtypes of structural scoliosis include congenital or acquired
Correct Answer: B
Rationale: The correct answer is B: It is reversible. Structural scoliosis involves irreversible changes in the spine's alignment, such as rotation and curvature due to factors like abnormal growth or spinal deformities. Reversibility is not a characteristic of structural scoliosis.
A: Most cases are idiopathic - This is a characteristic of structural scoliosis as idiopathic scoliosis is the most common type.
C: Subtype of structural scoliosis includes idiopathic - This supports the characteristic of idiopathic scoliosis within the structural category.
D: Subtypes of structural scoliosis include congenital or acquired - This is correct as structural scoliosis can be caused by congenital abnormalities or acquired conditions, supporting the definition of structural scoliosis.
Hypothermia is defined as ...
- A. An increase in body temperature over 96.8°
- B. A drop in body temperature below 96.8°
- C. Cyanosis
- D. None of the above
Correct Answer: B
Rationale: Hypothermia is a core temperature below 95°F (35°C), but 96.8°F (36°C) is a practical threshold for early detection . An increase over 96.8°F suggests normothermia or fever. Cyanosis is a symptom, not hypothermia. ‘None' is incorrect. Choice B is correct, aligning with nursing definitions (e.g., CDC) where subnormal temperature signals risk, guiding interventions like warming to prevent complications.
Which of the following percussion notes would you obtain over the gastric bubble?
- A. Resonance
- B. Tympany
- C. Hyperresonance
- D. Flatness
Correct Answer: B
Rationale: The correct answer is B: Tympany. When percussing over the gastric bubble, you would expect to hear a tympanic sound due to the presence of gas in the stomach. Tympany is characterized by a drum-like, hollow sound. Resonance (A) is a normal lung sound, hyperresonance (C) is indicative of hyperinflation of the lungs, and flatness (D) is typically heard over solid organs or areas of consolidation in the lungs. Therefore, the presence of a gastric bubble would produce a tympanic note on percussion.
A nurse is assessing a client's oxygen saturation level. What is the most common method used to measure oxygen saturation?
- A. Arterial blood gas analysis
- B. Capnography monitoring
- C. Pulse oximetry
- D. Spirometry testing
Correct Answer: C
Rationale: Pulse oximetry is the most common, non-invasive method for oxygen saturation. ABG is invasive. Capnography measures CO2. Spirometry assesses lung function. Choice C is correct, per the explanation, reflecting standard nursing practice.
Mark each of the following statements as therapeutic or nontherapeutic. c. "Dr. Daniels knows what he is talking about. Just follow his recommendations."
- A. Therapeutic
- B. Nontherapeutic
Correct Answer: B
Rationale: The correct answer is B: Nontherapeutic. This statement is nontherapeutic because it implies a lack of autonomy and empowerment for the individual seeking help. It suggests blindly following advice without considering personal preferences or values. This can hinder the therapeutic process by diminishing the client's ability to actively participate in decision-making and problem-solving. Therapeutic communication focuses on collaboration, empowerment, and respect for the client's autonomy. Choices A, C, and D are left blank as they do not provide a suitable rationale for the given question.