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. cortisone
- C. alcohol
- D. narcotics
Correct Answer: A
Rationale: Serotonin is a substance that is in the body and promotes sleep. Serotonin might play a role in synthesis of a hypnogenic factor that directly causes sleep. Drugs and alcohol can disrupt REM sleep, although they might accelerate the onset of sleep.
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Client room environments should include:
- A. a made bed, fresh water, thermostat regulation, and clean floors in all occupied client areas.
- B. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
- C. accident prevention, comfort, a room (including furniture) that has been cleaned with chloroseptic wash, a bed that is made every other day.
- D. odor control (by spraying the room with deodorizers), closet storage of all client objects, a clean room. (Gloves should be worn when cleaning.)
- E. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
Correct Answer: B
Rationale: Preparing a client's room environment should include making the client's bed, ensuring comfort and safety at all times, keeping the area free of clutter, and keeping the client's hygiene articles nearby. All procedures should be explained before they are performed, and the client should assist with personal arrangement of articles.
The nurse is using a hypothermia blanket for the febrile client. Which findings should prompt the nurse to consider that the client is hypothermic? Select all that apply.
- A. Increased urine output
- B. Increased drowsiness
- C. Decreased heart rate (HR)
- D. Decreased blood pressure (BP)
- E. Increased core body temperature
Correct Answer: B,C,D
Rationale: B: Drowsiness results from low cardiac output affecting the CNS. C: Decreased HR reflects thermoregulation effects. D: Decreased BP reduces cardiac workload. A: Hypothermia decreases urine output. E: Hypothermia lowers core temperature.
According to the ANA Code of Ethics for Nurses, professional nurses have an ethical obligation to:
- A. clients (patients)
- B. the profession of nursing
- C. provide high-quality care
- D. all of the above
Correct Answer: D
Rationale: The ANA Code of Ethics encompasses obligations to clients, the nursing profession, and delivering high-quality care, ensuring comprehensive ethical practice.
The client has asked if you would be able to offer any alternative or complementary therapy during their hospitalization. Which of the following would be appropriate to suggest? A. Physical therapy,B. Music therapy, C. Psychiatric therapy, D. Occupational therapy, E. Pet therapy
- A. B and E
- B. A and E
- C. C and D
- D. B and C
Correct Answer: A
Rationale: Music therapy and pet therapy are two forms of alternative or complementary therapy that may improve the client's condition and level of comfort. Physical, occupational, and/or psychiatric therapy are treatments that may be part of the client's care plan, and they are not considered complementary or alternative treatments. Additionally, they usually require a prescription or referral where music therapy and pet therapy typically do not.
The client is undergoing a 24-hour urine specimen collection. Twenty hours into the collection period, a single voided urine is accidentally discarded. What is the nurse's best action?
- A. Resume the urine collection and collect one additional voided specimen.
- B. Discard the urine collected and begin a new urine collection immediately.
- C. Complete the urine collection and send all urine collected to the laboratory.
- D. Dispose of the urine collected and reschedule the test to begin the next morning.
Correct Answer: B
Rationale: B: A discarded void invalidates the collection; restarting ensures accuracy. A: Adding a void causes inaccuracies. C: Missing a void compromises results. D: Rescheduling is unnecessary as the test can start anytime.