Nokea
The nurse is caring for an elderly female client who tells the nurse, 'When I sneeze, I wet my pants.' After discussing the client's complaint with the charge nurse, the nurse plans to reinforce teaching about the importance of Kegel exercises. What muscles are involved in these exercises?
- A. Pectoral muscles
- B. Buttock muscles
- C. Abdominal muscles
- D. Pelvic floor muscles
Correct Answer: D
Rationale: Kegel exercises involve the pelvic floor muscles. These muscles help strengthen the muscles controlling urination, potentially reducing symptoms of urinary incontinence. Pectoral muscles (Choice A), responsible for movement of the shoulders and arms, are not involved in Kegel exercises. Buttock muscles (Choice B) are primarily responsible for hip movement and stability, not related to Kegel exercises. Abdominal muscles (Choice C) support the core and trunk but are not the focus of Kegel exercises.
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The nurse is assigned to administer medications in a long-term care facility. A disoriented resident has no identification band or picture. What is the best nursing action for the nurse to take prior to administering the medications to this resident?
- A. Ask a regular staff member to confirm the resident's identity
- B. Hold the medication until a family member can confirm identity
- C. Re-orient the resident to name, place, and situation
- D. Confirm the room and bed numbers with those on the medication record
Correct Answer: A
Rationale: In a long-term care facility, when a disoriented resident lacks identification, it is crucial to confirm the resident's identity before administering medication to prevent errors. Asking a regular staff member who is familiar with the resident to confirm their identity is the best course of action. This ensures accuracy and safety in medication administration. Holding the medication until a family member can confirm the identity could delay necessary treatment. Re-orienting the resident is important for their well-being but does not address the immediate medication safety concern. Confirming room and bed numbers, though important for administration logistics, does not verify the resident's identity.
A male client who has been diagnosed with schizophrenia is withdrawn, isolates himself in the day room, and answers questions with one or two-word responses. This morning, the practical nurse observes that he is diaphoretic and is pacing in the hall. Which intervention is most important for the PN to implement?
- A. Persuade the client to lie down
- B. Provide a drink high in electrolytes
- C. Observe the client during the shift
- D. Measure appropriate vital signs
Correct Answer: D
Rationale: Measuring vital signs is crucial in this situation as it helps to determine if the client is experiencing a physical health issue or if the symptoms are related to a mental health crisis, such as anxiety or agitation. The presence of diaphoresis and pacing may indicate physiological changes requiring immediate attention. Providing a drink high in electrolytes or persuading the client to lie down may not address the underlying cause of the symptoms. Simply observing the client during the shift without taking necessary actions to assess his physiological status may delay appropriate intervention.
Which of the following is NOT a second-line agent used for the treatment of Tuberculosis?
- A. Amikacin
- B. Moxifloxacin
- C. Rifabutin
- D. Cycloserine
Correct Answer: C
Rationale: The correct answer is C, Rifabutin. Rifabutin is actually a first-line drug used in the treatment of tuberculosis. Choices A, B, and D (Amikacin, Moxifloxacin, and Cycloserine) are considered second-line agents for tuberculosis treatment. These drugs are used when the first-line medications are either ineffective or cannot be tolerated by the patient.
An 8-year-old is placed in 90-90 traction for a fractured femur resulting from a motor vehicle collision. Which finding requires further action by the PN?
- A. No bowel movement for two days
- B. Mother assists child in changing positions
- C. Weights are touching the foot of the bed
- D. Child is able to move the toes freely when tickled
Correct Answer: C
Rationale: In 90-90 traction, it is crucial to ensure that the weights are not touching the foot of the bed as this can disrupt the effective application of traction. This interference can hinder the proper alignment of the fractured femur and impede the healing process. Therefore, this finding requires immediate action to prevent complications. Choices A, B, and D are not directly related to the proper application of traction and do not pose a risk to the patient's treatment or well-being. No bowel movement for two days may indicate constipation but does not directly relate to the traction. Mother assisting the child in changing positions is a supportive action. The child being able to move the toes freely when tickled indicates neurological function, which is a positive sign.
What is the function of the epiglottis during swallowing?
- A. Prevents food from entering the trachea
- B. Aids in food propulsion
- C. Enhances taste sensation
- D. Lubricates the esophagus
Correct Answer: A
Rationale: The epiglottis is a flap of tissue that closes over the trachea during swallowing to prevent food and liquids from entering the airway. Choice A is correct because the primary function of the epiglottis is to act as a lid over the trachea, ensuring that food goes down the esophagus and not into the windpipe. Choices B, C, and D are incorrect as they do not describe the specific role of the epiglottis during swallowing.