Nokea
The nurse is caring for a client with a history of sickle cell anemia. Which intervention is most important during a sickle cell crisis?
- A. Administer oxygen
- B. Apply cold packs to joints
- C. Encourage bed rest
- D. Administer antibiotics
Correct Answer: A
Rationale: Sickle cell crisis causes vaso-occlusion, reducing tissue oxygenation. Administering oxygen is the priority to prevent hypoxia. Cold packs worsen vasoconstriction, rest is secondary, and antibiotics are for infections.
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A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be:
- A. Accepting her present body image
- B. Verbalizing realistic feelings about her body
- C. Having an improved perception of her body image
- D. Exhibiting increased self-esteem
Correct Answer: B
Rationale: This outcome criterion is inadequate because the term 'accepts' is not directly measurable. This outcome criterion is directly measurable because specific goal-related verbalizations can be heard and verified by the nurse. 'Improved perception of body image' is not directly measurable and is therefore open to many interpretations. Although long-term goals for the anorexic client should focus on increased self-esteem, this outcome criterion (as stated) does not include specific indicators or behaviors for which to observe.
Which term describes the play activity of the preschool aged child?
- A. Cooperative
- B. Associative
- C. Parallel
- D. Solitary
Correct Answer: B
Rationale: Preschool-aged children (3–5 years) typically engage in associative play, where they play together with shared activities but without formal rules or organization. Cooperative play develops later, parallel play is common in toddlers, and solitary play is seen in younger children.
The nurse is caring for a client with a closed head injury. Which intervention is most important to prevent increased intracranial pressure (ICP)?
- A. Keep the head of the bed elevated 30–45 degrees.
- B. Administer acetaminophen for headache.
- C. Provide frequent oral care.
- D. Encourage deep breathing exercises.
Correct Answer: A
Rationale: Elevating the head of the bed 30–45 degrees promotes venous drainage, reducing ICP. Acetaminophen (B), oral care (C), and breathing exercises (D) are supportive but less critical for ICP control.
A client with a history of a stroke is being discharged. The client’s wife asks the nurse how long it will take for her husband to regain his speech. The nurse’s response is based on the knowledge that:
- A. Speech therapy must begin immediately
- B. Most speech recovery occurs within 6 months
- C. Speech recovery cannot be predicted
- D. Speech therapy is not effective after 3 months
Correct Answer: B
Rationale: Most speech recovery post-stroke occurs within the first 6 months, though progress can continue with therapy. Recovery varies, but 6 months is a key period for significant improvement.
Which statement by the parent of a child with sickle cell anemia indicates an understanding of the disease?
- A. The pain he has is due to the presence of too many red blood cells.
- B. He will be able to go snow skiing with his friends as long as he stays warm.
- C. He will need extra fluids in summer to prevent dehydration.
- D. There is very little chance that his brother will have sickle cell.
Correct Answer: C
Rationale: Sickle cell anemia increases dehydration risk due to impaired blood flow, especially in heat. Extra fluids in summer prevent crises. Pain is due to vaso-occlusion, not excess RBCs, and skiing poses risks.