Nokea
What equipment would be necessary to complete an evaluation of cranial nerves 9 and 10 during a physical assessment?
- A. A cotton ball
- B. A penlight
- C. An ophthalmoscope
- D. A tongue depressor and flashlight
Correct Answer: D
Rationale: Cranial nerves 9 and 10 (glossopharyngeal and vagus) are assessed with a gag reflex, requiring a tongue depressor and light.
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Which of the following statement is NOT true about delegation in nursing?
- A. Assigning tasks
- B. Retains accountability
- C. Only to doctors
- D. Follows scope
Correct Answer: C
Rationale: Delegation assigns tasks (A), retains accountability (B), follows scope (D) 'only to doctors' (C) isn't true, includes aides, per standards. C's restriction misstates delegation's range, like to Mr. Gary's team, making it untrue.
The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis?
- A. Visual disturbances, including diplopia
- B. Ascending paralysis and loss of motor function
- C. Cogwheel rigidity and loss of coordination
- D. Progressive weakness that is worse at the day's end
Correct Answer: D
Rationale: Progressive weakness worse at day's end (fatigue) is classic in myasthenia gravis, due to acetylcholine receptor issues diplopia occurs but isn't primary, ascending paralysis fits Guillain-Barré, and rigidity is Parkinson's. Nurses assess this, aiding diagnosis, key for neuromuscular care.
Roger has been seen agitated, shouting and running. As Nurse Aida approaches, he shouts and swear, calling Aida names. Nurse Aida told Roger 'That is an unacceptable behavior Roger, Stop and go to your room now.' The situation is most likely in what phase of NPR?
- A. Pre Orientation
- B. Orientation
- C. Working
- D. Termination
Correct Answer: C
Rationale: This scenario fits the Working phase (C). Roger's agitation and Aida's response setting boundaries suggest an established relationship where interventions address behaviors. Pre-Orientation (A) is pre-contact, Orientation (B) builds trust, not confrontation, and Termination (D) ends care. In Peplau's Working phase, the nurse actively helps the client manage issues, as Aida does here, making C the likely phase.
The nurse reviewed Mr. Gary's care to reduce errors. This is an example of?
- A. Quality improvement
- B. Patient-centered care
- C. Nursing informatics
- D. Health promotion
Correct Answer: A
Rationale: Reviewing care to reduce errors is quality improvement (A) enhancing processes, per definition. Patient-centered (B) tailors, informatics (C) tech, promotion (D) well-being not error-focused. A fits QI's aim, making it correct.
The nurse allowed Mr. Gary to pray before his procedure as per his cultural practice. This is an example of?
- A. Cultural imposition
- B. Cultural competence
- C. Cultural ignorance
- D. Cultural bias
Correct Answer: B
Rationale: Allowing prayer per Mr. Gary's practice is cultural competence (B) respecting beliefs, per care standards. Imposition (A) forces norms, ignorance (C) neglects, bias (D) prejudges. B reflects adaptive, respectful care, ensuring his spiritual needs are met, making it correct.