Nokea
What term is used to describe a decreased effect of a substance following repeated exposure?
- A. Relapse
- B. Tolerance
- C. Abstinence
- D. Withdrawal.
Correct Answer: B
Rationale: Tolerance develops when repeated exposure to a substance diminishes its effects, requiring higher doses to achieve the same impact.
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Which term describes a nurse’s inability to differentiate between the beliefs of clients in the same culture?
- A. Generalization
- B. Stereotyping
- C. Ethnocentrism
- D. Cultural imposition
Correct Answer: B
Rationale: Stereotyping involves oversimplifying and applying generalized beliefs to individuals within a culture, hindering effective care.
A 27-year-old client who is three hours postoperative complains of right leg pain after knee reduction surgery. The first action by the nurse should be to:
- A. assess vital signs.
- B. elevate the extremity.
- C. perform a lower extremity neurovascular check.
- D. remind the client of the PCA pump and re-instruct the client on its use.
Correct Answer: C
Rationale: Vital signs may be altered if there is acute pain or complications related to bleeding or swelling, but it should not be assessed before checking the affected extremity. The extremity can be elevated if ordered by the physician. Assessment of the postoperative area is important to determine the presence of bleeding, swelling, or decreased circulation. Reinforcement of teaching on the use of the patient-controlled anesthesia (PCA) pump is important, but it is not the first action.
A confirmatory laboratory test for HIV includes
- A. Western blot.
- B. Low WBC.
- C. Comprehensive metabolic panel.
- D. Enzyme-linked immunosorbent assay (ELISA).
Correct Answer: A
Rationale: Western blot is used to confirm HIV infection.
Pain has been defined as “whatever the person experiencing the pain says it is, existing whenever the patient says it does.” This definition is problematic for the nurse when caring for which type of patient?
- A. A patient placed on a ventilator
- B. A patient with a history of opioid addiction
- C. A patient with decreased cognitive function
- D. A patient with pain resulting from severe trauma
Correct Answer: C
Rationale: The correct answer is C. Patients with decreased cognitive function may have difficulty communicating their pain, making this definition challenging.
A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For
which of the following client findings should the nurse intervene first?
- A. Urticaria
- B. Stridor
- C. Vomiting
- D. Hypotension
Correct Answer: B
Rationale: The correct answer is B: Stridor. Stridor is a high-pitched, inspiratory sound that indicates upper airway obstruction and impending respiratory distress, which is a life-threatening complication of anaphylaxis. The nurse should intervene first by ensuring a patent airway to prevent respiratory compromise. Urticaria (A) is a common symptom of an allergic reaction but does not pose an immediate threat to airway patency. Vomiting (C) can be a sign of gastrointestinal distress but does not require immediate intervention for airway protection. Hypotension (D) is a serious manifestation of anaphylaxis but addressing airway obstruction takes precedence to prevent respiratory failure.