Nokea
The nurse would monitor the client for which of the following?
- A. Trousseau’s sign
- B. Hypoglycemia
- C. Hypokalamia
- D. Respiratory changes
Correct Answer: A
Rationale: The correct answer is A: Trousseau's sign. This involves carpal spasm induced by inflating a blood pressure cuff above systolic pressure, indicating hypocalcemia. The nurse should monitor for this sign in clients at risk for low calcium levels. Hypoglycemia and hypokalemia have specific signs and symptoms not related to Trousseau's sign. Respiratory changes are nonspecific and may not be directly related to monitoring for low calcium levels.
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Which of the following nursing interventions is correctly categorized as collaborative?
- A. Administering medications as prescribed by the healthcare provider
- B. Ordering a low-sodium diet for a hypertensive client
- C. Providing health education about medication side effects
- D. Monitoring a client’s response to an intervention initiated by another healthcare professional
Correct Answer: D
Rationale: The correct answer is D because monitoring a client's response to an intervention initiated by another healthcare professional is a collaborative nursing intervention. This involves working together with other healthcare team members to assess the client's progress and adjust care as needed. It promotes continuity of care and ensures that the client's needs are met effectively.
A: Administering medications is typically an independent nursing intervention.
B: Ordering a low-sodium diet is within the scope of a nurse's independent practice.
C: Providing health education is often considered an independent nursing intervention unless it involves collaboration with other team members.
In summary, choice D is the correct answer as it exemplifies collaborative care within a healthcare team.
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
- A. The patient can now perform the dressing changes without help.
- B. The patient can begin retaking all of the previous medications.
- C. The patient is apprehensive about discharge.
- D. The patient’s surgery was not successful.
Correct Answer: C
Rationale: The correct answer is C. The nurse can infer that the patient is apprehensive about discharge based on the subjective data of the patient expressing fear of going home and being alone. This indicates the patient may not feel ready to leave the hospital setting. Choice A is incorrect because the patient's fear of going home suggests they may not be comfortable performing dressing changes alone. Choice B is incorrect because there is no information provided to support that the patient can begin retaking all previous medications. Choice D is incorrect as there is no indication that the fear of going home is related to the success of the surgery.
Which of the following is the most numerous type of white blood cell (WBC)?
- A. Neutrophil
- B. Basophil
- C. Eosinophil
- D. Lymphocyte
Correct Answer: A
Rationale: The correct answer is A: Neutrophil. Neutrophils are the most numerous type of WBC, typically comprising 50-70% of total WBC count. They are key players in the body's immune response, phagocytizing pathogens. Basophils, eosinophils, and lymphocytes are less numerous than neutrophils. Basophils are involved in allergic reactions, eosinophils combat parasitic infections, and lymphocytes play a critical role in adaptive immunity. However, in terms of sheer numbers, neutrophils outnumber the other types of WBC.
The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:
- A. pupil size, response to pain, motor responses
- B. Pupil size, verbal response, motor response
- C. Eye opening, verbal response, motor response
- D. Eye opening, response to pain, motor response J.E, is an 18-year old freshman admitted to the ICU following a motor vehicle accident in which he sustained multiple trauma including a ruptured spleen, myocardial contusion, fractured pelvis, and fractured right femur. He had a mild contusion, but is alert and oriented. His vital signs BP 120/80, pulse 84, respirations 12, and temperature 99 F orally.
Correct Answer: C
Rationale: The correct answer is C: Eye opening, verbal response, motor response. The Glasgow Coma Scale (GCS) assesses the level of consciousness by evaluating these three factors. Eye opening assesses the patient's ability to open their eyes spontaneously or in response to stimuli. Verbal response evaluates the patient's ability to speak or respond to verbal stimuli. Motor response assesses the patient's motor function by testing responses to commands or painful stimuli. Choice A is incorrect because it includes "response to pain" instead of "verbal response." Choice B is incorrect because it includes "verbal response" instead of "eye opening." Choice D is incorrect because it includes "eye opening" instead of "verbal response." In summary, the GCS evaluates eye opening, verbal response, and motor response to determine the level of consciousness in patients.
Which of the ff diets does the nurse recommend for clients with hypertension under the physicians guidance?
- A. The Food Guide Pyramid
- B. The South Beach Diet
- C. The Step One Diet
- D. The Dash diet
Correct Answer: D
Rationale: Step 1: The DASH diet is specifically designed to help lower blood pressure, making it the most appropriate choice for clients with hypertension.
Step 2: The DASH diet emphasizes fruits, vegetables, whole grains, lean proteins, and low-fat dairy, all of which are beneficial for managing hypertension.
Step 3: The diet also limits sodium intake, which is crucial for controlling blood pressure.
Step 4: The other options (A, B, and C) do not have the same evidence-based focus on hypertension management and may not be as effective in lowering blood pressure.