Nokea
The nurse reported Mr. Gary's fall to improve safety. This is an example of?
- A. Incident reporting
- B. Documentation
- C. Health promotion
- D. Care transition
Correct Answer: A
Rationale: Reporting a fall is incident reporting (A) adverse event log, per definition. Documentation (B) records, promotion (C) well-being, transition (D) moves not report-specific. A fits the nurse's action for Mr. Gary's safety, making it correct.
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The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
- A. Use the heel of her hand during percussion
- B. Change the child's position every 20 minutes
- C. Do percussion after the child eats and at bedtime
- D. Use cupped hands during percussion
Correct Answer: D
Rationale: Cupped hands during chest percussion loosen mucus in cystic fibrosis, creating vibrations without pain, a key physiotherapy technique to clear airways. Heel strikes are harsh, frequent repositioning isn't routine, and post-meal percussion risks reflux. Nurses teach this method for effective secretion management, improving breathing and reducing infection risk in this chronic condition.
This is the best patient care model when there are many nurses but few patients.
- A. Functional nursing
- B. Team nursing
- C. Primary nursing
- D. Total patient care
Correct Answer: D
Rationale: Total patient care excels with many nurses and few patients, allowing each nurse to fully address one client's needs e.g., bathing, meds, education. Functional nursing assigns tasks (e.g., one nurse for vitals), team nursing divides labor, and primary nursing focuses continuity, but ample staffing makes total care ideal. For instance, a nurse can devote time to a single ICU patient, optimizing outcomes. This model leverages resources for intensive, individualized attention, enhancing care quality in such scenarios.
Which of the following statement is NOT true about crisis intervention?
- A. Aims to restore pre-crisis state
- B. Short term
- C. Requires long term therapy
- D. Focuses on immediate needs
Correct Answer: C
Rationale: Crisis intervention restores pre-crisis (A), is short-term (B), immediate-focused (D) 'requires long-term therapy' (C) isn't true, as it's brief, per Caplan. C's duration contradicts, making it untrue.
The purpose of assessment is to:
- A. Establish a database concerning the client
- B. Delegate nursing responsibility
- C. Teach the client about his or her health
- D. Implement nursing care
Correct Answer: A
Rationale: Assessment's purpose is to establish a client database, collecting subjective (e.g., pain reports) and objective (e.g., blood pressure) data to understand health status comprehensively. This informs all nursing process steps diagnosis, planning, implementation, evaluation ensuring care is evidence-based. Delegating responsibility is a management task, not assessment's goal, which focuses on data, not task assignment. Teaching clients about health occurs later, using assessment findings, not defining its purpose. Implementing care follows planning, not assessment, which precedes action. By building a detailed picture e.g., a patient's asthma triggers assessment equips nurses to address needs accurately, making it the essential first step and primary purpose in delivering tailored, effective care.
Which of the following statement is NOT true about pulse pressure?
- A. Pulse pressure is the difference between the systolic and diastolic pressure
- B. Normal pulse pressure is 40 mmHg
- C. Pulse pressure increases when the systolic pressure is elevated and the diastolic pressure remains the same
- D. Elderly people have decreased pulse pressure due to loss of elasticity in the blood vessels
Correct Answer: D
Rationale: Pulse pressure is systolic minus diastolic (A), typically 40 mmHg (B), and rises if systolic increases with stable diastolic (C), per cardiovascular norms. Elderly have increased pulse pressure (D) due to arterial stiffness systolic rises, diastolic may drop making D untrue. Aging widens pulse pressure, not narrows it, contradicting D, thus it's the correct answer as the false statement.