Nokea
To attain the goal of ambulation for the patient who is hemiplegic, the initial care plan needs to be structured to first attain
- A. acceptance of his altered body image
- B. balance training
- C. adequate energy level
- D. ability to transfer from bed to chair
Correct Answer: D
Rationale: The ability to transfer from bed to chair is a critical first step in preparing a hemiplegic patient for ambulation. This foundational skill builds confidence and strength before progressing to balance training or walking.
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A client is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago and is now 88/50 mm Hg. What action by the nurse is best?
- A. Call the Rapid Response Team.
- B. Document and continue to monitor.
- C. Notify the primary care provider.
- D. Repeat blood pressure measurement in 15 minutes.
Correct Answer: A
Rationale: The correct answer is A: Call the Rapid Response Team. A significant drop in blood pressure from 142/76 mm Hg to 88/50 mm Hg indicates a potential life-threatening condition like hypovolemic shock. Calling the Rapid Response Team allows for immediate assessment and intervention to stabilize the client. Other choices are incorrect because documenting and monitoring without intervention can lead to deterioration, notifying the primary care provider may cause delays in critical care, and repeating the blood pressure measurement in 15 minutes may worsen the client's condition if urgent intervention is needed.
What is a typical parasomnia?
- A. Cataplexy
- B. Hypopnea
- C. Sleep apnea
- D. Sleep terrors
Correct Answer: D
Rationale: The correct answer is D. Sleep terrors are a classic example of parasomnias, which are abnormal behaviors during sleep. Cataplexy (A) is associated with narcolepsy, hypopnea (B) refers to shallow breathing, and sleep apnea (C) involves breathing interruptions.
A nursing assistant asks why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is your best response?
- A. “The client's low phosphorus is probably due to malnutrition.”
- B. “The client is just worn out from not getting enough rest.”
- C. “The client's skeletal muscles are weak because of the low phosphorus.”
- D. “The client will do more for herself when her phosphorus is normal.”
Correct Answer: C
Rationale: Low phosphorus levels impair energy production in cells, leading to muscle weakness and fatigue, which explains the need for assistance.
When auscultating Mr. Puff’s chest, what would you expect to find?
- A. Absent breath sounds
- B. Bronchial breath sounds with rales
- C. Decreased vesicular breath sounds with prolonged expiration
- D. Normal breath sounds with prolonged inspiration
Correct Answer: C
Rationale: Air trapping causes prolonged expiration in COPD.
On assessment of a patient’s learning needs, the nurse determines that a patient taking potassium-wasting diuretics does not know what foods are high in potassium. What is an appropriate nursing diagnosis for this patient?
- A. Risk for cardiac dysrhythmias related to low potassium intake
- B. Deficient knowledge related to not knowing what foods are high in potassium
- C. Imbalanced nutrition: less than body requirements related to lack of intake of potassium-rich foods
- D. Deficient knowledge related to lack of interest regarding dietary requirements when taking diuretics
Correct Answer: B
Rationale: The correct answer is 'Deficient knowledge related to not knowing what foods are high in potassium.' This nursing diagnosis directly addresses the identified learning need. While other options may be indirectly relevant, the primary issue here is the patient's lack of knowledge about potassium-rich foods.