Nokea
The nurse notices that the client has a hematocrit of 70 percent. This level of hematocrit will most likely affect the vital signs in which of the following ways?
- A. The blood pressure will be elevated.
- B. The pulse will be low.
- C. Temperature will be elevated.
- D. Blood pressure will be low.
Correct Answer: A
Rationale: A 70% hematocrit, abnormally high, increases blood viscosity, elevating blood pressure, not lowering pulse or raising temperature. Nurses monitor this for circulatory strain.
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A client with a new diagnosis of anemia is being taught about dietary management. Which of the following statements should be included in the teaching?
- A. You should increase your intake of foods high in iron.
- B. You should decrease your intake of foods high in calcium.
- C. You should avoid foods that contain gluten.
- D. You should increase your intake of high-fat foods.
Correct Answer: A
Rationale: The correct answer is A: 'You should increase your intake of foods high in iron.' This statement should be included in the teaching because increasing intake of foods high in iron is essential for managing anemia. Iron is a key component for producing hemoglobin, which carries oxygen in the blood. By increasing iron-rich foods like leafy greens, red meat, and fortified cereals, the client can help improve their hemoglobin levels and overall health. Choices B, C, and D are incorrect. Decreasing intake of foods high in calcium is not necessary for anemia management; avoiding foods that contain gluten is relevant for individuals with gluten sensitivity or celiac disease, not anemia; and increasing intake of high-fat foods is not recommended for managing anemia.
It is best described as a systematic, rational method of planning and providing nursing care for individuals, families, group and community
- A. Assessment
- B. Nursing Process
- C. Diagnosis
- D. Implementation
Correct Answer: B
Rationale: The nursing process (B) is a comprehensive, systematic framework used by nurses to deliver patient-centered care. It encompasses five steps: assessment (data collection), diagnosis (identifying health problems), planning (setting goals and interventions), implementation (carrying out the plan), and evaluation (assessing outcomes). This definition matches the description in the question as a rational, organized method applicable to individuals, families, groups, and communities. Assessment (A) is only the first step, not the entire method. Diagnosis (C) is a single phase focused on problem identification, while implementation (D) is the action phase, neither encompassing the full scope described. The nursing process integrates critical thinking and evidence-based practice to ensure holistic care, making B the accurate answer reflecting its broad, systematic nature.
The nurse is performing a physical assessment on a client with a history of gout. The nurse should assess the client for:
- A. Pain and swelling of the affected joint
- B. Increased urinary output
- C. Fever with a temperature greater than 101°F
- D. Numbness in the affected extremity
Correct Answer: A
Rationale: Pain and swelling of the affected joint (often the big toe) are classic gout signs due to uric acid crystal deposits increased urine, fever, or numbness aren't typical. Nurses assess for redness and warmth, guiding anti-inflammatory treatment, critical for managing this metabolic disorder's acute flares.
According to Maslow, which of the following is TRUE about a self actualized person?
- A. Makes decision contrary to public opinion
- B. Do not predict events
- C. Self centered
- D. Maximum degree of self conflict
Correct Answer: A
Rationale: Maslow's self-actualized individual (1940s) decides independently e.g., rejecting popular trends for personal ethics. They predict events (insightful), aren't self-centered (altruistic), and minimize conflict through clarity. Nurses encourage this autonomy e.g., supporting a patient's unconventional treatment choice enhancing self-directed health decisions.
The nurse is assessing the client for abdominal distention, which of the following technique should be performed by the nurse?
- A. Inspection alone is sufficient
- B. Inspection and Palpation
- C. Inspection and Percussion
- D. Inspection, Palpation and Percussion
Correct Answer: C
Rationale: Abdominal distention needs inspection (e.g., bloating) and percussion (e.g., tympany for gas) unlike inspection alone or palpation (tenderness). Nurses use e.g., tap for cause, per assessment.