Nokea
The nurse is caring for a client with a T4 spinal cord injury. Which finding indicates that the client is experiencing neurogenic shock?
- A. Blood pressure 82/40 mm Hg, pulse 48 beats/min
- B. Blood pressure 150/90 mm Hg, pulse 110 beats/min
- C. Blood pressure 110/70 mm Hg, pulse 88 beats/min
- D. Blood pressure 130/80 mm Hg, pulse 62 beats/min
Correct Answer: A
Rationale: Neurogenic shock in T4 SCI features hypotension and bradycardia (A, 82/40, 48 bpm) from sympathetic loss. Hypertension/tachycardia (B) suggests dysreflexia. C and D are normalish. A is correct. Rationale: Loss of vasomotor tone below T4 causes vasodilation and unopposed vagal activity, per SCI pathophysiology, requiring fluids and atropine.
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The parents of a healthy 6-year-old ask the nurse for advice about preventing obesity in their child. Which response reflects health promotion?
- A. Limit screen time and encourage outdoor play.'
- B. Weigh your child monthly to monitor for weight gain.'
- C. Give your child a multivitamin daily to prevent obesity.'
- D. Have your child's cholesterol checked annually.'
Correct Answer: A
Rationale: For a healthy 6-year-old, health promotion prevents obesity by fostering active habits limiting screen time and encouraging outdoor play boosts physical activity, burning calories and building muscle, key to avoiding weight gain at this age. Evidence links sedentary screen hours to childhood obesity; play counters it, aligning with nursing's focus on lifestyle over surveillance. Monthly weighing is secondary, tracking not preventing, and may stress the child. Multivitamins don't prevent obesity caloric balance does while annual cholesterol checks detect, not avert, issues. The nurse's reply promotes wellness through fun, practical steps like biking or tag tailored to a child's energy, ensuring long-term health without medicalizing a well kid, a cornerstone of pediatric nursing's preventive approach.
The nurse allowed Mr. Gary to pray before his procedure as per his cultural practice. This is an example of?
- A. Cultural imposition
- B. Cultural competence
- C. Cultural ignorance
- D. Cultural bias
Correct Answer: B
Rationale: Allowing prayer per Mr. Gary's practice is cultural competence (B) respecting beliefs, per care standards. Imposition (A) forces norms, ignorance (C) neglects, bias (D) prejudges. B reflects adaptive, respectful care, ensuring his spiritual needs are met, making it correct.
The nurse gave Mr. Gary his medication as planned. This is an example of?
- A. Implementation
- B. Planning
- C. Evaluation
- D. Assessment
Correct Answer: A
Rationale: Giving medication as planned is implementation (A) executing care, per process. Planning (B) sets, evaluation (C) assesses, assessment (D) gathers not action-specific. A fits intervention delivery, making it correct.
Which of the following statement best describe cultural competence?
- A. Ignoring client's cultural beliefs
- B. Providing care that respects cultural differences
- C. Forcing client to follow hospital culture
- D. Treating all clients the same way
Correct Answer: B
Rationale: Cultural competence is providing care respecting cultural differences (B), per nursing standards tailoring to beliefs (e.g., diet, rituals). Ignoring (A), forcing (C), or sameness (D) dismiss diversity. B best defines competence as culturally sensitive care, aligning with Purnell's model, making it correct.
You highly suspect that your assigned client has abdominal distention. You most need to do and chart which of the following things?
- A. Have another nurse verify your suspicions.
- B. Measure the abdominal girth at the umbilicus.
- C. Measure abdominal girth at the most distended level.
- D. Ask the client if they are distended.
Correct Answer: C
Rationale: Measuring girth at the most distended level and charting it confirms abdominal distention objectively, critical for tracking. Verification, umbilicus measurement, or client query are less precise. Nurses rely on this for accurate monitoring.