Nokea
What interventions should the nurse implement in caring for a client with diabetes insipidus (DI) following a head injury? Select all that apply.
- A. Providing adequate fluids within easy reach
- B. Reporting an increasing urine specific gravity
- C. Administering prescribed erythromycin
- D. Assessing for and reporting changes in neurological status
Correct Answer: A
Rationale: For diabetes insipidus (DI) post-head injury, providing fluids (A) prevents dehydration from polyuria. Increasing urine specific gravity (B) contradicts DI's dilute urine. Erythromycin (C) is unrelated. Neurological changes (D) are monitored but secondary. A is correct. Rationale: Fluid replacement matches DI's excessive output, a primary intervention per endocrine care standards, maintaining hydration.
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Which of the following statement best describe spiritual care in nursing?
- A. Ignoring beliefs
- B. Supporting spiritual needs
- C. A medical fix
- D. A one-time talk
Correct Answer: B
Rationale: Spiritual care is supporting spiritual needs (B), per nursing e.g., prayer support. Not ignoring (A), not medical (C), not one-time (D) holistic focus. B best defines its role, enhancing Mr. Gary's well-being, making it correct.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) receiving long-term oxygen therapy at home. What should the nurse include in the client's teaching regarding oxygen safety?
- A. Ensure you have a fire extinguisher readily available
- B. Keep the oxygen tubing loose to prevent tangling
- C. Avoid using electric heating devices in your home
- D. Use an oxygen concentrator for outdoor activities
Correct Answer: C
Rationale: Avoiding electric heating devices (C) is critical in COPD oxygen therapy teaching, as oxygen accelerates combustion, posing a fire risk. Fire extinguisher (A) is supplementary. Loose tubing (B) risks disruption. Concentrator use (D) depends on need. Safety education, per home care standards, prioritizes fire prevention.
The goal of nursing is to put the patient in the best condition for nature to act upon him'. This was stated by
- A. Henderson
- B. Jean Watson
- C. Marta Rogers
- D. Florence Nightingale
Correct Answer: D
Rationale: This quote reflects a historical view of nursing as facilitating natural healing, attributed to Florence Nightingale, the founder of modern nursing. In her 1859 work, *Notes on Nursing*, she emphasized optimizing the patient's environment cleanliness, air, and rest for recovery. Henderson defined nursing through 14 basic needs, Watson focused on caring theory, and Rogers developed a science of unitary beings none match this phrasing. Nightingale's philosophy shaped nursing's focus on holistic care, influencing practice for centuries by prioritizing patient conditions over direct intervention.
The nurse is preparing a client with an axillopopliteal bypass graft for discharge. The client should be taught to avoid:
- A. Using a recliner to elevate the legs
- B. Walking long distances
- C. Sitting in a chair for long periods
- D. Sleeping in a flat position
Correct Answer: C
Rationale: Sitting in a chair for long periods post-axillopopliteal bypass risks kinking the graft or pooling blood, impairing circulation and healing a key discharge caution. Elevating legs, walking, or lying flat supports venous return and graft patency. Nurses teach this to prevent thrombosis or occlusion, ensuring clients maintain mobility and positioning to optimize surgical outcomes and limb perfusion.
The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should tell the parents:
- A. That the infant will need daily calcium supplements
- B. To lift the infant by the buttocks when diapering
- C. That the condition is a temporary one
- D. That only the bones are affected by the disease
Correct Answer: B
Rationale: Lifting by the buttocks prevents fractures in osteogenesis imperfecta, a brittle bone disorder calcium doesn't strengthen defective collagen, it's lifelong, and other systems (e.g., hearing) may be affected. Nurses teach gentle handling, ensuring safety in this genetic condition.