Nokea
What is the most likely reason for a hospitalized adult client who routinely works from midnight until 8 a.m. to have a temperature of 99.1°F at 4 a.m.?
- A. delta sleep
- B. slow brain waves
- C. pneumonia
- D. circadian rhythm
Correct Answer: D
Rationale: The correct answer is 'circadian rhythm.' Circadian rhythms are biological cycles that last about 24 hours. The sleep-wake cycle is closely tied to circadian rhythms, affecting body temperature. Normally, core body temperature drops during sleep, reaching its 24-hour low around 4 a.m. In this case, the client's temperature of 99.1°F at 4 a.m. is likely due to the disruption of their circadian rhythm caused by working from midnight until 8 a.m. Choices A, B, and C are incorrect because delta sleep, slow brain waves, and pneumonia do not directly explain the temperature fluctuation based on circadian rhythm.
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What does it mean to be a nursing advocate?
- A. makes decisions for others.
- B. encourages persons to make decisions for themselves and acts with or on behalf of the person to support those decisions.
- C. manages the care of others.
- D. is the legal representative for a person.
Correct Answer: B
Rationale: A nursing advocate does not make decisions for others but instead empowers individuals to make decisions for themselves. By encouraging individuals to make their own decisions and supporting them in this process, nursing advocates uphold the principle of self-determination. This approach respects the autonomy and independence of individuals in managing their care. Therefore, the correct answer is to 'encourage persons to make decisions for themselves and act with or on behalf of the person to support those decisions.' Choices A, C, and D are incorrect as they do not align with the role of a nursing advocate in promoting patient autonomy and self-determination.
A safety measure to implement when transferring a client with hemiparesis from a bed to a wheelchair is:
- A. standing the client and walking him or her to the wheelchair.
- B. moving the wheelchair close to the client's bed and standing and pivoting the client on his unaffected extremity to the wheelchair.
- C. moving the wheelchair close to the client's bed and standing and pivoting the client on his affected extremity to the wheelchair.
- D. having the client stand and push his body to the wheelchair.
Correct Answer: B
Rationale: When transferring a client with hemiparesis from a bed to a wheelchair, it is crucial to ensure their safety. The correct safety measure involves moving the wheelchair close to the client's bed and having the client stand and pivot on his unaffected extremity to the wheelchair. This method provides support with the unaffected limb, reducing the risk of falls and promoting a safer transfer. Choice A is incorrect because walking the client is unsafe and not recommended. Choice C is incorrect as pivoting the client on his affected extremity can lead to injury or falls due to weakness or lack of control. Choice D is incorrect as it puts the client at risk by requiring them to push their body, which may not be feasible or safe for someone with hemiparesis.
The healthcare provider is using Cognitive-Behavioral methods of pain control and knows that these methods can be expected to do all the following except:
- A. completely relieve all pain.
- B. provide benefit by restoring the client's sense of self-control.
- C. help the client to control symptoms.
- D. help the client actively participate in his or her care.
Correct Answer: A
Rationale: Cognitive-Behavioral methods of pain control aim to provide benefit by restoring the client's sense of self-control, helping the client to control symptoms, and encouraging the client to actively participate in their care. However, these methods are not intended to completely relieve all pain. These interventions focus on perception and thought, aiming to influence how one interprets events and bodily sensations. Therefore, the correct answer is that they cannot completely relieve all pain, as pain relief is often a multifaceted approach that may require additional interventions beyond Cognitive-Behavioral methods. Choices B, C, and D are correct as Cognitive-Behavioral methods are designed to empower the individual in managing their pain and improving their overall well-being.
How many temporary teeth should the nurse expect to find in a 5-year-old client's mouth?
- A. up to 10
- B. up to 15
- C. up to 20
- D. up to 32
Correct Answer: C
Rationale: A 5-year-old child can have up to 20 temporary (deciduous or baby) teeth. The first tooth usually erupts by age 6 months, and the last by age 30 months. All temporary teeth are usually shed between 6 and 13 years of age. Therefore, a 5-year-old child should have up to 20 temporary teeth. The correct answer is 'up to 20.' Choices A, B, and D are incorrect because the correct number of temporary teeth in a 5-year-old child's mouth is up to 20, not 10, 15, or 32.
A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client's record reflects the correct use of guidelines for documentation?
- A. The client's wound is healing well.
- B. The client seems anxious.
- C. The client's intake was 360 mL
- D. The client is voiding large amounts
Correct Answer: C
Rationale: Quality documentation and reporting require information to be factual, accurate, complete, current, and organized. Choice C, 'The client's intake was 360 mL,' reflects the correct use of guidelines for documentation as it provides a specific and measurable observation. This note meets the criteria for quality documentation by being specific and quantifiable. Choices A, B, and D lack specificity and quantifiability. Choice A includes a subjective term 'well,' choice B uses 'seems' indicating uncertainty, and choice D uses a vague term 'large' without quantifying the amount.