Nokea
When examining a patient who is paralyzed below the T4 level, the medical-surgical nurse expects to find
- A. flaccidity of the upper extremities.
- B. hyperreflexia and spasticity of the upper extremities.
- C. independent use of upper extremities and efficient cough.
- D. impaired diaphragmatic function requiring ventilator support.
Correct Answer: C
Rationale: Patients paralyzed below T4 typically retain independent use of upper extremities.
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What should a nurse include in the teaching plan for clients who have a potential for hypovolemia?
- A. Avoid alcohol and caffeine
- B. Increase intake of dried peas and beans
- C. Increase intake of milk and dairy products
- D. Avoid table salt or food containing sodium
Correct Answer: A
Rationale: Alcohol and caffeine are diuretics, increasing fluid loss and worsening hypovolemi Avoiding them helps maintain fluid balance.
A client is being admitted to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority?
- A. Bowel sounds
- B. Surgical dressing
- C. Temperature
- D. Oxygen saturation
Correct Answer: D
Rationale: The correct answer is D: Oxygen saturation. The priority assessment after a cholecystectomy is monitoring the client's oxygen saturation to ensure adequate oxygenation post-surgery. Decreased oxygen saturation can indicate respiratory distress, which requires immediate intervention. Bowel sounds (A) are important but not the priority post-cholecystectomy. Surgical dressing (B) should be assessed, but it is not as critical as monitoring oxygen saturation. Temperature (C) is also important, but ensuring oxygenation takes precedence in the immediate postoperative period.
When should discharge planning begin for a patient in a tertiary-care facility?
- A. On the day of admission
- B. After the acute crisis is resolved
- C. When the physician writes the discharge order
- D. When the patient demonstrates readiness to discuss posthospitalization needs
Correct Answer: A
Rationale: Rationale:
A: Discharge planning should begin on the day of admission to ensure a smooth transition. This early start allows for comprehensive assessment and coordination of post-discharge needs.
B: Waiting until after the acute crisis is resolved may lead to rushed planning and potential gaps in care.
C: Discharge planning should not solely rely on the physician's discharge order as it may not address all aspects of the patient's needs.
D: Patient readiness is important, but starting planning early ensures sufficient time for assessment and interventions.
While caring for a client receiving positive-pressure mechanical ventilation, which intervention should the nurse NOT implement to prevent complications?
- A. Elevate the head of the bed to at least 30°.
- B. Verify the prescribed ventilator settings daily.
- C. Administer pantoprazole as prescribed.
- D. Reposition the endotracheal tube to the opposite side of the mouth daily.
Correct Answer: D
Rationale: The correct answer is D. Repositioning the endotracheal tube to the opposite side of the mouth daily is not necessary and could potentially lead to complications such as accidental extubation or damage to the airway. A: Elevating the head of the bed helps prevent aspiration. B: Verifying ventilator settings daily ensures proper functioning. C: Administering pantoprazole helps prevent stress ulcers. In summary, D is incorrect because it is unnecessary and poses risks, while A, B, and C are important interventions to prevent complications associated with positive-pressure mechanical ventilation.
Which theorist discussed adaptive and maladaptive behaviors?
- A. F. Skinner
- B. Harry Stack Sullivan
- C. Erik Erikson
- D. Sigmund Freud
Correct Answer: A
Rationale: F. Skinner's behaviorist theory emphasizes how behaviors are learned through reinforcement and punishment.