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What is the nurse’s firstaction?
- A. Follow the clinical protocol for a stroke.
- B. Review the most recent lab results for the patient’s potassium level. Assess the patient for other symptoms or problems, and then notify the health care
- C. provider. Administer an antihypertensive medication from the stock supply, and then notify the
- D. health care provider.
Correct Answer: B
Rationale: The correct answer is B. First, reviewing lab results for potassium level is important in assessing potential electrolyte imbalances that may contribute to the patient's symptoms. This allows for a comprehensive understanding of the patient's condition. Assessing the patient for other symptoms or problems is crucial to gather additional information. Finally, notifying the healthcare provider ensures timely communication and collaboration for appropriate care. Choice A is incorrect as following a clinical protocol for a stroke is premature without a comprehensive assessment. Choice C is incorrect as administering medication without a thorough assessment and provider notification can be dangerous. Choice D is incorrect as notifying the healthcare provider should precede administering any medication.
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A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing?
- A. Collaborative
- B. Independent
- C. Interdependent
- D. Dependent
Correct Answer: D
Rationale: The correct answer is D: Dependent. In this scenario, the nurse is administering pain medication based on a healthcare provider's prescription, which demonstrates a dependent nursing intervention. The nurse is reliant on the provider's order to carry out this action. Collaborative interventions involve working with other healthcare professionals, independent interventions are actions that nurses can initiate without supervision, and interdependent interventions involve mutual goal-setting and decision-making among healthcare team members.
Which of the ff. statements does the nurse understand is true concerning air conduction of sound in the ear?
- A. It is caused by the vibration of bones in the skull.
- B. It is less efficient than bone conduction.
- C. It is heard longer than bone conduction.
- D. It is caused by transmission of heat through the air.
Correct Answer: B
Rationale: The correct answer is B because air conduction is less efficient than bone conduction due to the sound waves traveling through the air in the ear canal, which can be hindered by factors like blockages or obstructions. This results in a weaker and less clear sound transmission compared to bone conduction, where sound waves are transmitted directly through the bones of the skull, bypassing any potential obstructions in the ear canal.
Incorrect choices:
A: This statement is incorrect as air conduction of sound in the ear is not caused by the vibration of bones in the skull.
C: This statement is incorrect as air conduction is typically heard for a shorter duration than bone conduction.
D: This statement is incorrect as air conduction of sound in the ear is not caused by the transmission of heat through the air, but rather by sound waves traveling through the ear canal.
Why are older adults with heart and blood vessel diseases susceptible to thrombophlebitis?
- A. Choose all that apply
- B. IV drugs and chemicals
- C. Impaired mobility
- D. Compromised circulation
Correct Answer: B
Rationale: The correct answer is B: IV drugs and chemicals. Thrombophlebitis is inflammation of a vein with blood clot formation, commonly caused by irritants like IV drugs. Impaired mobility (C) and compromised circulation (D) are risk factors for thrombophlebitis, but not specific to older adults with heart and blood vessel diseases. A is incorrect as not all choices apply in this scenario.
Clients with myastherda gravis, Guillain - Barre Syndrome or amyothrophic sclerosis experience:
- A. Progressive deterioration until death
- B. Deficiencies of essential neurotransmitter
- C. Increased risk of respiratory complications
- D. Involuntary twitching of small muscle group
Correct Answer: C
Rationale: The correct answer is C: Increased risk of respiratory complications. Clients with myasthenia gravis, Guillain-Barre Syndrome, or amyotrophic lateral sclerosis all experience muscle weakness, including respiratory muscles, leading to a higher risk of respiratory complications such as difficulty breathing or respiratory failure. This is due to the involvement of the neuromuscular system in these conditions. Choices A, B, and D are incorrect because they do not directly correlate with the respiratory complications commonly seen in these specific neuromuscular disorders.
Which of the following settings is most therapeutic for an agitated head-injured patient?
- A. A day room with family visitors and variety of caregivers
- B. A semiprivate room with one or two consistent caregivers
- C. A ward with other head-injured patients and volunteers to assist with needs
- D. A hallway near the nurse’s station with adequate sensory stimulation
Correct Answer: B
Rationale: The correct answer is B. A semiprivate room with one or two consistent caregivers is the most therapeutic setting for an agitated head-injured patient. Here's the rationale:
1. Consistency: Having one or two consistent caregivers provides the patient with a stable and familiar environment, which can help reduce agitation.
2. Privacy: A semiprivate room offers more privacy compared to a day room or a ward, which can help minimize external stimuli and promote relaxation.
3. Individualized care: In a semiprivate room, caregivers can focus more on the specific needs of the patient, leading to better management of agitation.
4. Reduced distractions: Being in a semiprivate room minimizes distractions and noise, which can be overwhelming for an agitated head-injured patient.
Summary:
A, C, and D are incorrect because they do not offer the same level of consistency, privacy, individualized care, and reduced distractions as a semiprivate room with one