Nokea
What is an important nursing measure in the rehabilitation of an older adult to prevent loss of function from inactivity and immobility?
- A. Using assistive devices such as walkers and canes
- B. Teaching good nutrition to prevent loss of muscle mass
- C. Performance of active and passive range-of-motion (ROM) exercises
- D. Performance of risk appraisals and assessments related to immobility
Correct Answer: C
Rationale: Active and passive ROM exercises preserve mobility and prevent complications arising from prolonged immobility.
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A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, Will my children have cystic fibrosis? How should the nurse respond?
- A. Since many of your family members are carriers, your children will also be carriers of the gene.
- B. Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder.
- C. Since you have a family history of cystic fibrosis, I would encourage you & your partner to be tested.
- D. Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder.
Correct Answer: C
Rationale: Rationale:
C is correct because it encourages genetic testing for both the client and their partner to assess the risk of passing on the cystic fibrosis gene. This approach provides the necessary information for informed decision-making regarding family planning. A is incorrect because being a carrier does not guarantee that the children will also be carriers. B is incorrect as it inaccurately states that if the client is a carrier, their children will have the disorder. D is incorrect because it oversimplifies the etiology of cystic fibrosis and suggests dietary adjustments as a solution, which is not effective in managing the genetic condition.
4. What is the focus of the integrative model of health care?
- A. Costs paid by insurance
- B. Treatment of symptoms
- C. Mind-body-spirit connections
- D. Care directed by nurse practitioners
Correct Answer: C
Rationale: The integrative model emphasizes holistic care, focusing on the mind-body-spirit connections rather than just treating symptoms or relying solely on conventional treatments.
A client is scheduled for a cholecystectomy in the morning. In planning the postoperative care, the priority nursing diagnosis for the client will be at high-risk for:
- A. knowledge deficit.
- B. urinary retention.
- C. impaired physical mobility.
- D. ineffective breathing pattern.
Correct Answer: D
Rationale: The client may have a knowledge deficit, but reducing the risk for knowledge deficit is not a postoperative priority nursing diagnosis. The client will have a Foley catheter for a day or two after the surgery. Urinary retention is usually not a problem once the Foley catheter is removed. A client having a cholecystectomy should not be physically impaired. The client is encouraged to begin ambulating soon after surgery. Because of the location of the incision, the cholecystectomy client is reluctant to breath deeply and is at risk for developing pneumonia. These clients have to be reminded and encouraged to take deep breaths.
After auscultating a client's breath sounds, the nurse is providing care. Which finding is correctly matched to the nurse's primary intervention?
- A. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate.
- B. Crackles are heard in bases. The nurse encourages the client to cough forcefully.
- C. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator.
- D. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply.
Correct Answer: C
Rationale: Step 1: Wheezes indicate narrowing of the airways, typically seen in conditions like asthma.
Step 2: Inhaled bronchodilators help dilate the airways, relieving wheezing and improving breathing.
Step 3: Hence, administering an inhaled bronchodilator is the correct intervention for wheezes.
Summary:
A: Increasing oxygen flow does not directly address the issue of wheezes.
B: Encouraging coughing does not address the narrowing of airways seen with wheezes.
D: Deep breathing does not specifically target the narrowing of airways associated with wheezes.
Place the steps of the evidence-based practice (EBP) process in order (0 being the first step; 6 being the last step).
- A. Create a spirit of inquiry
- B. Ask a clinical question
- C. Critically analyze the evidence
- D. Make recommendations for practice or generate data
Correct Answer: B
Rationale: The EBP process begins with creating a spirit of inquiry, followed by asking a clinical question, finding and analyzing evidence, making recommendations, and evaluating outcomes.