Nokea
The nurse is caring for a client following a right total hip replacement. Which action by the nurse will help prevent dislocation of the prosthesis?
- A. Keeping the client's knees together at all times
- B. Placing the client in a supine position with the legs extended
- C. Placing a pillow between the client's legs when turning
- D. Encouraging the client to use the trapeze to pull himself up in bed
Correct Answer: C
Rationale: Placing a pillow between the legs during turning maintains abduction, preventing hip prosthesis dislocation post-right total hip replacement knees together adducts, supine extension risks posterior dislocation, and trapeze use is safe but unrelated. Nurses enforce this, ensuring joint stability, key for orthopedic recovery.
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Nursing identifies its domain in a paradigm that includes:
- A. The person, health, environment/situation and nursing
- B. Concepts, theory, health and environment
- C. Health, person, environment and theory
- D. Nurses, physicians, models and client needs
Correct Answer: A
Rationale: Nursing's paradigm comprises person (client), health (well-being goal), environment/situation (context), and nursing (practice) a metaparadigm unifying theories like Nightingale's or Watson's. This defines nursing's scope, focusing on client care holistically. Concepts, theory, health, and environment are abstract, not a complete paradigm missing 'person' and 'nursing.' Health, person, environment, and theory swap 'nursing' for 'theory,' confusing framework with product. Nurses, physicians, models, and needs mix roles and tools, not core concepts. The person, health, environment, and nursing quartet encapsulates nursing's domain, guiding practice and research comprehensively.
The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician's teaching by telling the parents that:
- A. The medication will be needed only during times of rapid growth
- B. The medication will be needed throughout the child's lifetime
- C. The medication schedule can be arranged to allow for drug holidays
- D. The medication is given one time daily every other day
Correct Answer: B
Rationale: Lifetime thyroid hormone replacement is needed for congenital hypothyroidism to prevent developmental delays growth spurts, holidays, or alternate days don't suffice. Nurses reinforce this, ensuring adherence, critical for normal growth in this endocrine disorder.
Growth chart is also known as:
- A. New Ballard Scale
- B. Road to health chart
- C. Apgar Score
- D. GCS Score
Correct Answer: B
Rationale: Growth charts track child development. New Ballard Scale (choice A) assesses gestational age, not growth. Road to health chart (choice B), per WHO, plots weight-for-age, monitoring nutrition and health longitudinally. Apgar Score (choice C) evaluates newborns at birth, not growth. GCS Score (choice D, Glasgow Coma Scale) assesses consciousness. B is correct, synonymous with growth charts. Nurses use it to detect malnutrition, educate caregivers, and guide interventions, ensuring child well-being.
Which of the following statement best describe a health care proxy?
- A. A medical diagnosis
- B. A person chosen to decide
- C. A hospital policy
- D. A treatment plan
Correct Answer: B
Rationale: A health care proxy is a person chosen to decide (B), per definition e.g., surrogate for incapacity. Not diagnosis (A), policy (C), plan (D) decision-maker. B best defines proxy's role, like Mr. Gary appointing someone, making it correct.
Which of the following is true about the NURSING CARE PLAN?
- A. It is nursing centered
- B. Rationales are supported by interventions
- C. Verbal
- D. Atleast 2 goals are needed for every nursing diagnosis
Correct Answer: A
Rationale: The nursing care plan is nursing-centered (A), focusing on nurse-led actions, per planning standards. Rationales support interventions (B) reverses logic, verbal (C) isn't typical, two goals (D) isn't required. A aligns with purpose, making it correct.