Nokea
The nurse is teaching a client who underwent a hypophysectomy for hypopituitarism about self-management. Which actions performed by the client could cause complications on the second post-operative day? Select all that apply.
- A. Nose blowing
- B. Teeth brushing
- C. Bending forward
- D. Lying in a semi-Fowler's position
Correct Answer: A
Rationale: Post-hypophysectomy, nose blowing (A) risks CSF leak or meningitis by disrupting the surgical site. Brushing (B) and semi-Fowler's (D) are safe. Bending (C) is risky but less immediate. A is correct. Rationale: Nasal pressure can breach the pituitary fossa repair, a critical complication in early recovery, per post-operative neurosurgery care, unlike benign actions.
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In what phase of Nurse patient relationship does a nurse review the client's medical records thereby learning as much as possible about the client?
- A. Pre Orientation
- B. Orientation
- C. Working
- D. Termination
Correct Answer: A
Rationale: In the Pre-Orientation phase (A), the nurse reviews records to gather data about the client before meeting, preparing for interaction. Orientation (B) begins with the first encounter, building trust. Working (C) involves goal-focused collaboration, and Termination (D) ends the relationship. Pre-Orientation is distinct as it's preparatory, not interactive, aligning with Peplau's model where understanding the client starts pre-contact, making A correct.
How should the nurse prepare an injection for a patient who takes both regular and NPH insulin?
- A. Draw up the NPH insulin, then the regular insulin, in the same syringe
- B. Draw up the regular insulin, then the NPH insulin, in the same syringe
- C. Use two separate syringes
- D. Check with the physician
Correct Answer: B
Rationale: Regular (clear) is drawn first, then NPH (cloudy), to avoid contamination.
The nurse is aware that the normal frequency of bowel sounds is
- A. 1-5 gurgles/minute
- B. 5-35 gurgles/minute
- C. 35-60 gurgles/minute
- D. 60-100 gurgles/minute
Correct Answer: B
Rationale: Normal bowel sounds are 5-35 gurgles/minute e.g., peristalsis per norms. Less (hypoactive), more (hyperactive) differ. Nurses count e.g., 1 minute for function, per standards.
The nurse cares for 4 clients. Which activity demonstrates the nurse's understanding of how ethnicity influences the client's health?
- A. Provide financial resources from local organizations to pay for a client's health care needs.
- B. Teach a client using drawings, repetition, short sentences, and simple language.
- C. Assess a 5-month-old African American client for sickle cell anemia.
- D. Explain the consequences of not exercising and only eating fast food due to a stressful job.
Correct Answer: C
Rationale: Ethnicity influences health through genetic predispositions and cultural factors. Assessing a 5-month-old African American client for sickle cell anemia (C) reflects this, as the disease is prevalent in African descent populations due to a genetic mutation. Providing financial resources (A) addresses access, not ethnicity-specific health. Teaching with simple methods (B) aids comprehension but isn't ethnicity-tied. Diet and exercise advice (D) is general, not ethnic-specific. C is correct. Rationale: Sickle cell anemia's higher incidence in African Americans requires early screening to prevent complications like vaso-occlusive crises, showcasing culturally competent care rooted in genetic epidemiology, unlike the other options.
Which of the following is recognized for developing the concept of HIGH LEVEL WELLNESS?
- A. Erikson
- B. Madaw
- C. Peplau
- D. Dunn
Correct Answer: D
Rationale: Halbert Dunn's High-Level Wellness (1950s) concept frames health as maximizing potential within environmental limits e.g., thriving despite chronic illness. Unlike Erikson's stages, Madaw (unknown), or Peplau's relations, Dunn's idea influences nursing's focus on optimal functioning, not just disease absence, shaping wellness programs.