Nokea
What information should be immediately reported to the physician?
- A. The ingested children's chewable vitamins contain iron
- B. The child has been treated several times for ingestion of toxic substances
- C. The child has been treated several times for accidental injuries
- D. The child was nauseated and vomited once at home
Correct Answer: A
Rationale: Iron ingestion can cause severe toxicity and requires immediate medical attention.
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A 64-year-old male client is admitted to the hospital with benign prostatic hypertrophy (BPH). The client has a history of adult onset diabetes mellitus and hypertension. He is scheduled to undergo a resection of the prostate. The most serious symptom that may accompany BPH is:
- A. acute urinary retention.
- B. hesitancy in starting urination.
- C. increased frequency of urination.
- D. decreased force of the urinary stream.
Correct Answer: A
Rationale: Acute urinary retention is a symptom of BPH, is serious, and requires urgent medical attention. Hesitancy in starting urination is a symptom of BPH, but it is not serious or life-threatening. Increased frequency of urination is a symptom of BPH, but it is not serious or life-threatening. Decreased force of the urinary stream is due to an obstruction, but it is not serious or life-threatening.
What is the definition of substance abuse?
- A. A compulsive need to experience pleasure
- B. Behavior associated with maintaining an addiction
- C. Absence of a substance will cause withdrawal symptoms
- D. Overuse and dependence on a substance that negatively affects functioning.
Correct Answer: D
Rationale: Substance abuse involves overuse and dependence on a substance leading to negative impacts on one's life, encompassing both physical and social consequences.
While caring for an unconscious patient, the nurse discovers a stage 2 pressure ulcer on the patient’s heel. During care of the ulcer, what is the nurse’s understanding of the patient’s perception of pain?
- A. The patient will have a behavioral response if pain is perceived.
- B. The area should be treated as a painful lesion, using gentle cleansing and dressing.
- C. The area can be thoroughly scrubbed because the patient is not able to perceive pain.
- D. All nociceptive stimuli that are transmitted to the brain result in the perception of pain.
Correct Answer: B
Rationale: The correct answer is B. Even in unconscious patients, the area should be treated gently to avoid exacerbating potential pain.
Which of the following would be appropriate to delegate to the nursing assistant?
- A. Assist the child to remove outer clothing
- B. Advise the parent to use acetaminophen instead of aspirin
- C. Explain the need for cool fluids
- D. Prepare and administer a tepid bath
Correct Answer: A
Rationale: Removing outer clothing is a simple task that does not require clinical judgment.
To offer the most effective program with the best outcomes, the nurses should initially
- A. Search for an article that describes nursing interventions that are effective for smoking cessation
- B. Develop a clinical question that will allow them to compare different cessation methods during the program
- C. Keep comprehensive records that detail each patient’s progress and ultimate outcomes from participation in the program
- D. Use evidence-based clinical practice guidelines developed from reviews of randomized controlled trials of smoking cessation methods
Correct Answer: D
Rationale: Using evidence-based guidelines ensures the program is grounded in proven methodologies, leading to better outcomes.