Nokea
The nurse is preparing to take vital signs in an alert client admitted with dehydration secondary to vomiting and diarrhea. What is the best method to assess the client's temperature?
- A. Oral
- B. Axillary
- C. Radial
- D. Heat sensitive tape
Correct Answer: B
Rationale: Axillary is safest and most accessible for a dehydrated client with GI issues, avoiding oral route due to vomiting and diarrhea.
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Which of the following nursing intervention is appropriate when an IV infusion infiltrates?
- A. Elevate the site
- B. Discontinue the infusion
- C. Attempt to flush the tube
- D. Apply warm, moist compress
Correct Answer: B
Rationale: IV infiltration (fluid in tissues) requires discontinuing the infusion to stop further leakage, preventing swelling or tissue damage. Elevation reduces edema post-removal, flushing worsens infiltration, and warm compresses aid absorption later. Nurses prioritize stopping the source, then assess for complications like phlebitis, ensuring patient comfort and vein integrity.
The nurse working in the community is assigned to the care of several clients. Which client(s) may require assistance to overcome barriers to accessing adequate care?
- A. A student entering a local university
- B. A client who is a migrant and works on a farm
- C. An older adult client living independently
- D. A client who has been unemployed for 6 months
Correct Answer: B
Rationale: Barriers to healthcare access often hit vulnerable groups hardest, requiring nursing intervention. A migrant farm worker faces language, mobility, and economic hurdles, limiting care access e.g., no insurance or transport. An older adult living alone may struggle with mobility, health literacy, or isolation, delaying treatment. An unemployed client, lacking income or coverage, often skips care due to cost, risking worsening conditions. A student entering university or an employed pregnant client typically has fewer systemic barriers students may access campus health, employed clients insurance. Nursing must target the migrant, elderly, and jobless, addressing disparities poverty, age, ethnicity ensuring equitable care. This reflects nursing's equity mission, bridging gaps for those society sidelines, enhancing health outcomes through advocacy and resource linkage.
The physician has ordered amitriptyline (Elavil) for a client with depression. The nurse should tell the client that:
- A. The medication will produce a rapid improvement in mood
- B. He might experience difficulty with urination
- C. He should avoid milk products while taking the medication
- D. The medication should be discontinued if he experiences dry mouth
Correct Answer: B
Rationale: Difficulty with urination is a common amitriptyline side effect (anticholinergic), needing monitoring mood improvement takes weeks, milk isn't restricted, and dry mouth doesn't warrant stopping. Nurses teach this, managing expectations, ensuring adherence in depression treatment.
Which of the following statement best describe implementation in nursing process?
- A. Identifying problems
- B. Setting goals
- C. Carrying out interventions
- D. Evaluating outcomes
Correct Answer: C
Rationale: Implementation is carrying out interventions (C), per nursing process e.g., giving meds. Not identifying (A), setting (B), evaluating (D) action-focused. C best defines implementation's execution, making it correct.
Mr. Gary drinks alcohol to forget his stress. This is an example of?
- A. Adaptive coping
- B. Maladaptive coping
- C. Health promotion
- D. Wellness
Correct Answer: B
Rationale: Drinking to forget stress is maladaptive coping (B) ineffective, harmful, per Lazarus (e.g., addiction risk). Adaptive (A) helps, health promotion (C) enhances, wellness (D) state not coping type. B fits short-term escape, making it correct.