When giving a client a diagnosis of acute pain, the nurse 'using NANDA diagnostic categories' will use this diagnosis only when the pain last no longer than which of the following lengths of time?
- A. 3 days
- B. 2 weeks
- C. 1 month
- D. 6 months
Correct Answer: D
Rationale: NANDA defines acute pain as lasting up to 6 months, beyond which it's chronic. Nurses use this timeframe for diagnosis accuracy.
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The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
- A. Use the heel of her hand during percussion
- B. Change the child's position every 20 minutes
- C. Do percussion after the child eats and at bedtime
- D. Use cupped hands during percussion
Correct Answer: D
Rationale: Cupped hands during chest percussion loosen mucus in cystic fibrosis, creating vibrations without pain, a key physiotherapy technique to clear airways. Heel strikes are harsh, frequent repositioning isn't routine, and post-meal percussion risks reflux. Nurses teach this method for effective secretion management, improving breathing and reducing infection risk in this chronic condition.
Who is the first Filipino chief nurse of PGH?
- A. Rosario Delgado
- B. Anastacia Giron Tupas
- C. Julita Sotejo
- D. Loreto Tupas
Correct Answer: B
Rationale: Anastacia Giron-Tupas, PGH's first Filipino chief nurse, marked a shift to local leadership e.g., post-American rule. Delgado (PNA president), Sotejo (educator), and Tupas differ. Her tenure elevated Filipino roles, influencing nursing's national identity and autonomy.
Which actions are examples of an RN participating in illness prevention for a client with hypertension?
- A. Teaching lifestyle modifications
- B. Reporting low blood pressure to the health care provider
- C. Administering ordered medication
- D. Performing risk screenings for hypertension
Correct Answer: A
Rationale: Illness prevention in nursing focuses on proactive measures to stop disease development, particularly for conditions like hypertension. Teaching lifestyle modifications, such as diet and exercise, empowers clients to manage blood pressure and reduce risk, aligning with primary prevention's educational emphasis. Performing risk screenings identifies hypertension early, enabling timely intervention before complications arise, another primary prevention strategy. Providing heart-healthy diet literature reinforces these efforts, equipping clients with practical tools for prevention. Reporting low blood pressure or administering medications, while critical interventions, address existing conditions rather than prevent onset, falling under treatment or management. Nurses' preventive role leverages education and screening to foster healthy habits and early detection, significantly impacting chronic disease trajectories like hypertension, where lifestyle plays a pivotal role.
A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client's body temperature?
- A. Oral
- B. Axillary
- C. Arterial line
- D. Rectal
Correct Answer: B
Rationale: Axillary avoids the oral route post-surgery and is appropriate for a flushed, warm client.
Which of the following statement is NOT true about Hospice care?
- A. Offered to terminally ill client
- B. The client's family is included in the care
- C. Focuses on relieving symptoms
- D. Requires client to sign a DNR
Correct Answer: D
Rationale: Hospice cares for terminally ill (A), includes family (B), and relieves symptoms (C), per hospice philosophy. Requiring a DNR (D) isn't true preferred, not mandatory; care focuses on comfort, not resuscitation status. D's absolute requirement misaligns with flexibility, making it the untrue statement.
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