Nokea
The nurse is teaching a client about sleep and gives background information on normal sleep patterns. Which of the following substances promotes sleep?
- A. serotonin
- B. cortisol
- C. alcohol
- D. narcotics
Correct Answer: A
Rationale: Serotonin is a substance found in the body that promotes sleep. It plays a role in the synthesis of a hypnogenic factor that directly induces sleep. Cortisol is a stress hormone that can disrupt sleep patterns. Alcohol can disrupt REM sleep and negatively impact sleep quality. Narcotics, like alcohol, can interfere with sleep architecture and lead to poor quality sleep. Therefore, the correct answer is serotonin as it is associated with promoting sleep, while the other substances listed can have negative effects on sleep patterns.
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Hearing screening of prematurely born infants is an effective means of identifying disease and is an example of:
- A. Primary prevention.
- B. Secondary prevention.
- C. Tertiary prevention.
- D. Disability prevention.
Correct Answer: B
Rationale: The correct answer is B: Secondary prevention. Hearing screening for prematurely born infants falls under secondary prevention, which aims to identify and treat a condition in its early stages to prevent further complications. Primary prevention (choice A) focuses on preventing the disease from occurring, while tertiary prevention (choice C) involves managing complications and preventing disability. Choice D, disability prevention, is not a recognized category of prevention. In this context, the screening helps in early identification of hearing loss, allowing for timely intervention to prevent further impairment or complications, aligning with the principles of secondary prevention.
A licensed practical nurse (LPN) works on an adult medical/surgical unit and has been pulled to work on the burn unit, which cares for clients of all ages. What should the LPN do?
- A. The LPN should take the assignment, but make it clear they will only care for adult clients.
- B. The LPN should take the assignment, but explain the situation to the charge nurse and ask for a quick orientation before starting.
- C. The LPN should refuse to take the assignment, as caring for the infant and child population is not within their scope of practice.
- D. The LPN should take the assignment, but ask to be paired with a more experienced LPN.
Correct Answer: B
Rationale: In this scenario, it is crucial for the LPN to demonstrate flexibility and a willingness to adapt to the new assignment that involves caring for clients of all ages. While the LPN may have expertise in a specific nursing area, it is essential to be able to provide care to diverse client populations. Accepting the assignment reflects a commitment to teamwork and patient care. However, to ensure safe and competent care, the LPN should communicate with the charge nurse about the situation. Requesting a quick orientation will help the LPN familiarize themselves with the burn unit's specific requirements, equipment, and protocols. This proactive approach allows the LPN to address any concerns, ask questions, and seek necessary support, ultimately ensuring the best care for all clients in the burn unit.
Choice A is incorrect because limiting care to only adult clients may not be feasible in a unit that cares for clients of all ages. Choice C is incorrect as refusing the assignment outright may not be the best approach without considering alternatives. Choice D is not the most effective option as asking to be paired with a more experienced LPN does not address the need for a quick orientation to the new unit.
A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client's record reflects the correct use of guidelines for documentation?
- A. The client's wound is healing well.
- B. The client seems anxious.
- C. The client's intake was 360 mL
- D. The client is voiding large amounts
Correct Answer: C
Rationale: Quality documentation and reporting require information to be factual, accurate, complete, current, and organized. Choice C, 'The client's intake was 360 mL,' reflects the correct use of guidelines for documentation as it provides a specific and measurable observation. This note meets the criteria for quality documentation by being specific and quantifiable. Choices A, B, and D lack specificity and quantifiability. Choice A includes a subjective term 'well,' choice B uses 'seems' indicating uncertainty, and choice D uses a vague term 'large' without quantifying the amount.
What condition is mammography used to detect?
- A. pain
- B. tumor
- C. edema
- D. epilepsy
Correct Answer: B
Rationale: Mammography is specifically used to detect tumors or abnormal growths, especially in breast tissue. It is not a tool for identifying pain, edema, or epilepsy. Therefore, the correct answer is 'tumor.' Pain is a symptom, edema is swelling, and epilepsy is a neurological disorder; none of these are conditions typically detected through mammography.
A nurse is supervising a new nursing graduate in various procedures. Which action by the new nursing graduate constitutes a negligent act?
- A. Giving a verbal report to the nurse on the oncoming shift
- B. Checking neurological signs in a client with a head injury
- C. Contacting a healthcare provider about a change in a client's blood pressure
- D. Using clean gloves to change a gastrostomy tube dressing
Correct Answer: D
Rationale: Negligent acts in nursing include various errors that can harm the client, such as medication errors, intravenous therapy errors, burns, falls, failure to use aseptic technique, failure to provide adequate monitoring, and failure to report significant changes in a client's condition. In this scenario, using clean gloves to change a gastrostomy tube dressing is a negligent act because sterile gloves should be used when changing a dressing over broken skin. Choices A, B, and C are not negligent acts as they involve appropriate nursing actions: giving a verbal report, checking neurological signs, and contacting a healthcare provider about a change in a client's blood pressure.