Nokea
The nurse is caring for a client with a suspected myocardial infarction. Which laboratory value is most specific for confirming the diagnosis?
- A. Troponin I
- B. Creatine kinase (CK)
- C. Myoglobin
- D. Lactic dehydrogenase (LDH)
Correct Answer: A
Rationale: Troponin I is the most specific marker for myocardial infarction, rising within hours and staying elevated for days CK and myoglobin are less specific, LDH is outdated. Nurses monitor this, correlating with ECG and symptoms, aiding rapid diagnosis and treatment.
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These are nursing intervention that requires knowledge, skills and expertise of multiple health professionals.
- A. Dependent
- B. Independent
- C. Interdependent
- D. Intradependent
Correct Answer: C
Rationale: Interdependent interventions rely on multiple health professionals' expertise, such as a nurse, physiotherapist, and doctor co-managing a stroke patient's rehab plan. Dependent actions follow orders (e.g., giving meds), independent ones are nurse-initiated (e.g., repositioning), and 'intradependent' isn't a term. For instance, adjusting a patient's diet with a nutritionist reflects shared knowledge, ensuring holistic care. This collaboration, common in complex cases, leverages diverse skills, enhancing outcomes like mobility or nutrition, a hallmark of modern interdisciplinary healthcare teams.
Client has undergone Upper GI and Lower GI series. Which type of health assessment framework is used in this situation?
- A. Functional health framework
- B. Head to toe framework
- C. Body system framework
- D. Cephalocaudal framework
Correct Answer: C
Rationale: Upper and Lower GI series use a body system framework (C), targeting digestive system, per assessment types. Functional (A) assesses ADLs, head-to-toe (B) and cephalocaudal (D) are physical sweeps. C fits organ focus, making it correct.
Your assigned client seems to be getting a lot of attention from his mother when he complains of pain. The mother may be encouraging which of the following types of gains?
- A. primary gains
- B. secondary gains
- C. narcissistic gains
- D. egocentric gains
Correct Answer: B
Rationale: Maternal attention for pain suggests secondary gains external benefits beyond primary relief or other gains. Nurses address this in behavioral pain management.
One tablet of chlorine is efficient to chlorinate how many litres of water?
- A. 10 Litres
- B. 20 Litres
- C. 30 Litres
- D. 40 Litres
Correct Answer: B
Rationale: Chlorine tablets disinfect water by releasing hypochlorous acid to kill pathogens. Standard tablets (e.g., 1 mg chlorine) are designed to treat specific volumes based on concentration needs (typically 0.5-2 mg/L). Choice A (10 L) underestimates common tablet capacity, while C (30 L) and D (40 L) exceed typical single-tablet efficacy without specifying tablet strength. B (20 L) aligns with widely used chlorine tablets (e.g., NaDCC) for household water purification, achieving safe levels per WHO guidelines. Nurses educating communities on water safety must clarify dosage, ensuring effective pathogen control without overdose, making 20 L the correct, practical answer.
One of your assigned clients gets up to go to the bathroom without calling you. The client falls to the floor and calls for help. You answer the call and alert your supervisor. After assuring that the vital signs are normal and there does not appear to be any injuries, you are told to fill out an incident report. In addition to noting that the client was found on the floor, which of the following statements would you most need to record in the nursing notes for the client?
- A. Incident report completed.'
- B. the reason the client was unattended
- C. the vital signs and assessment of the client
- D. location of the incident report
Correct Answer: C
Rationale: After a fall, recording vital signs and assessment in nursing notes is most needed, providing a clinical picture post-incident like stable pulse and no fractures for care and legal purposes. Noting the report's completion or location is administrative, and explaining absence justifies but doesn't document health status. This ensures comprehensive client-focused documentation.