Nokea
Until doctor's orders are received, the most appropriate position for Mr. Jones, admitted with retinal detachment, is lying
- A. flat on his back
- B. on his left side
- C. on his right side
- D. on his abdomen
Correct Answer: B
Rationale: Lying on the affected side (left side) helps reduce movement of the detached retina, minimizing further damage until definitive treatment can be administered.
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The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?
- A. Evaluate chest expansion.
- B. Check pupillary response to light.
- C. Assess the capillary refill.
- D. Check the client's response to questions about place and time.
Correct Answer: A
Rationale: The correct answer is A: Evaluate chest expansion. This is the priority action because it assesses the client's airway and breathing, which are critical for survival. Checking chest expansion helps to identify any potential respiratory compromise or underlying lung injuries. Assessing pupillary response (B) and capillary refill (C) are important, but they are secondary to ensuring adequate oxygenation. Checking the client's orientation to place and time (D) is important for neurological assessment but is not as critical as assessing airway and breathing in this scenario.
During surgery, a patient has a nursing diagnosis of risk for perioperative positioning injury. What is a common risk factor for this nursing diagnosis?
- A. Skin lesions
- B. Break in sterile technique
- C. Musculoskeletal deformities
- D. Electrical or mechanical equipment failure
Correct Answer: C
Rationale: Musculoskeletal deformities increase the risk of positioning injuries during surgery.
What is the basic premise of Ayurvedic medicine?
- A. Views disease as resulting from disharmony with Mother Earth,possession by an evil spirit or violation of a taboo.
- B. Health is the outcome of balancing yin and yang,opposite forces that must remain equalized to maintain life’s energy force.
- C. Help individuals become unified with nature to develop a strong body,clear mind and tranquil spirit.
- D. Correcting an imbalance between two attributes such as motion and stillness or hot and cold restores harmony and health.
Correct Answer: C
Rationale: Ayurveda emphasizes unity with nature to promote holistic well-being.
An 80-year-old woman is brought to the emergency department by her daughter, who says her mother has refused to eat for 6 days. The mother says she stays in her room all of the time because the family is mean to her when she eats or watches TV with them. She says her daughter brings her only one meal a day and that meal is cold leftovers from the family’s meals days before.
- A. Neglect
- B. Emotional abuse
- C. Weight loss
- D. Decreased muscle mass
Correct Answer: A
Rationale: The scenario describes neglect (insufficient food provision) and emotional abuse (isolation due to perceived meanness).
A patient with chronic cancer-related pain has started using MS Contin for pain control and has developed common side effects of the drug. The nurse reassures the patient that tolerance will develop to most of these side effects but that continued treatment will most likely be required for what?
- A. Pruritus
- B. Constipation
- C. Dizziness
- D. Nausea and vomiting
Correct Answer: B
Rationale: The correct answer is B. Constipation is a persistent side effect of opioids.