Nokea
Type of recording that integrates all data about the problem, gathered by members of the health team.
- A. POMR
- B. Traditional
- C. Resource oriented
- D. Source oriented
Correct Answer: A
Rationale: POMR (Problem-Oriented Medical Record) (A) integrates team data per problem, per Weed's system. Traditional (B) and source-oriented (D) separate by discipline. Resource-oriented (C) isn't recognized. A fits interdisciplinary focus, making it correct.
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A client who experienced a traumatic brain injury has a Glasgow Coma Scale score of 6 and is at risk for increased intracranial pressure (ICP). Which position should the nurse maintain for this client?
- A. Supine with head turned to the right
- B. Prone with the head straight
- C. Semi-Fowler's at 30 degrees
- D. High Fowler's at 90 degrees
Correct Answer: C
Rationale: For a GCS of 6 with ICP risk, semi-Fowler's at 30 degrees (C) optimizes venous drainage, reducing ICP. Supine (A) or prone (B) increases pressure. High Fowler's (D) may destabilize. C is correct. Rationale: 30-degree elevation balances ICP reduction and perfusion, per neurocare standards, critical in severe brain injury.
The physician has ordered amitriptyline (Elavil) for a client with depression. The nurse should tell the client that:
- A. The medication will produce a rapid improvement in mood
- B. He might experience difficulty with urination
- C. He should avoid milk products while taking the medication
- D. The medication should be discontinued if he experiences dry mouth
Correct Answer: B
Rationale: Difficulty with urination is a common amitriptyline side effect (anticholinergic), needing monitoring mood improvement takes weeks, milk isn't restricted, and dry mouth doesn't warrant stopping. Nurses teach this, managing expectations, ensuring adherence in depression treatment.
The nurse is completing a health history with an older adult client who reveals smoking one pack of cigarettes daily for the past 50 years. Which illness prevention strategy should the nurse recommend?
- A. Referral to a smoking cessation program
- B. Screening for lung cancer
- C. Referral to a nutritionist
- D. Mobility exercises
Correct Answer: A
Rationale: For an older adult with a 50-year, pack-a-day smoking history, the nurse prioritizes illness prevention via a smoking cessation program referral primary prevention to halt further damage from a modifiable risk tied to lung cancer, COPD, and heart disease. Quitting slashes these risks studies show even late cessation improves lung function. Screening for lung cancer is secondary, detecting issues, not preventing them, though relevant later. Nutrition or mobility exercises enhance wellness but don't address smoking's root threat 20% of smokers develop COPD. Cessation directly targets the habit, aligning with nursing's preventive ethos, offering practical support like group therapy or nicotine aids. This strategy empowers the client to alter a decades-long risk, maximizing health gains despite age, a cornerstone of tailored care.
Which one of the following is the commonest side effects of copper-T :
- A. Pain
- B. Bleeding
- C. Perforation
- D. Ectopic pregnancy
Correct Answer: B
Rationale: Copper-T, an intrauterine device (IUD), has known side effects, with bleeding being the most frequent. Pain (choice A) occurs, especially during insertion or cramping, but it's typically transient. Bleeding (choice B), including heavier periods or spotting, affects most users due to copper's inflammatory effect on the endometrium, often leading to discontinuation. Perforation (choice C) is rare, occurring in <1/1000 insertions, and ectopic pregnancy (choice D) is a serious but uncommon risk, as IUDs primarily prevent intrauterine implantation. B is correct, as clinical data consistently show bleeding as the commonest complaint. Nurses must educate patients on expected bleeding patterns, monitor for anemia, and assess when intervention (e.g., removal) is needed, ensuring informed use of this contraceptive method.
Which of the following is NOT true about BP?
- A. BP is dependent on blood volume, Cardiac output and peripheral resistance
- B. BP is dependent on age and body weight
- C. The BP on the left arm is higher than the right
- D. BP is taken on the left arm because it is nearest to the heart
Correct Answer: C
Rationale: BP depends on blood volume, cardiac output, and peripheral resistance (A), and varies with age and weight (B), per cardiovascular physiology. The left arm isn't inherently higher (C) it's false; differences are minimal and individual. Left arm use (D) is convention, not proximity (it's not significantly closer). C's absolute claim lacks evidence, making it the untrue statement, as BP symmetry is typical unless pathology exists.