Nokea
When inspecting the client's eyelids for ptosis, the nurse is checking for which abnormality?
- A. Drooping
- B. Pupil dilation
- C. Pupil constriction
- D. Deviation of ocular movements
Correct Answer: A
Rationale: When a nurse inspects a client's eyelids for ptosis, they are checking for drooping. Ptosis is a condition characterized by the drooping of the eyelids and can be associated with various disorders such as myasthenia gravis, dysfunction of cranial nerve III, and Bell's palsy. Pupil dilation and constriction are assessed using a flashlight to check pupillary response. Deviation of ocular movements is evaluated by leading the client's eyes through the six cardinal positions of gaze. Therefore, in this scenario, the correct answer is 'Drooping' as it specifically relates to the abnormality associated with ptosis.
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What is the primary theory that explains a family's concept of health and illness?
- A. Health Belief Model
- B. Education Factor
- C. Family Health Belief Model
- D. Family Dynamics Model
Correct Answer: A
Rationale: The correct answer is the Health Belief Model. The Health Belief Model is a widely recognized theory that explains individuals' perceptions and behaviors related to health and illness. It considers factors such as perceived susceptibility, severity of health issues, benefits of action, and barriers to taking action. Choices B, C, and D are incorrect. Choice B, 'Education Factor,' is too general and does not specifically address a family's concept of health and illness. Choice C, 'Family Health Belief Model,' is a combination of terms and not a recognized theory. Choice D, 'Family Dynamics Model,' focuses on family interactions rather than explaining a family's concept of health and illness.
An assessment of the skull of a normal 10-month-old baby should identify which of the following?
- A. closure of the posterior fontanel.
- B. closure of the anterior fontanel.
- C. overlap of cranial bones.
- D. ossification of the sutures.
Correct Answer: B
Rationale: The correct answer is the closure of the anterior fontanel. By 10 months of age, the anterior fontanel should be closed. The posterior fontanel should actually close by the age of 2 months, making choice A incorrect. Overlap of cranial bones is not a typical finding in a normal 10-month-old baby's skull, so choice C is incorrect. Ossification of the sutures is an ongoing process in skull development and should not be a definitive indicator at this age, making choice D incorrect.
What is the intent of the Patient Self Determination Act (PSDA) of 1990?
- A. Enhance personal control over healthcare decisions.
- B. Encourage medical treatment decision making prior to need.
- C. Establish a federal standard for living wills and durable powers of attorney.
- D. Emphasize client education.
Correct Answer: B
Rationale: The correct answer is B: The purpose of the PSDA is to encourage medical treatment decision-making before it becomes necessary. This legislation aims to empower individuals to make their own healthcare choices in advance. Choice A is incorrect because while enhancing personal control over healthcare decisions is important, the primary goal of the PSDA is to facilitate medical decision-making before the need arises. Choice C is incorrect as the PSDA does not establish a federal standard for living wills and durable powers of attorney; instead, it encourages individuals to create their own advance directives according to state-specific regulations. Choice D is incorrect because while client education is valuable, the main focus of the PSDA is on empowering individuals to plan for their future healthcare needs.
The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?
- A. The client should remove all scatter rugs from the floor and minimize clutter.
- B. The client should not limit her movement within the home unless advised by the physician.
- C. The client should have a raised toilet seat and grab bars available in the bathroom.
- D. The client should not wear a robe and socks while walking in the house.
Correct Answer: A
Rationale: The correct answer is to instruct the client to remove all scatter rugs from the floor and minimize clutter. Rugs and clutter are common causes of falls in the home, especially for the elderly or those with gait issues. Removing them can significantly reduce the risk of falls. While having a raised toilet seat and grab bars in the bathroom is important for safety, it is not the priority in this scenario. The client should not limit her movement within the home unless specifically advised by the physician, as maintaining mobility is essential for recovery. Lastly, the client should avoid wearing robes and socks while walking in the house to prevent tripping, slipping, or falling on slippery floors.
What is the primary focus of a case manager?
- A. Addressing nursing care needs at discharge.
- B. Managing the comprehensive care needs of the client for continuity of care.
- C. Providing client education needs upon discharge.
- D. Securing financial resources for needed care.
Correct Answer: B
Rationale: The correct answer is 'Managing the comprehensive care needs of the client for continuity of care.' Case managers oversee all aspects of a client's care to ensure continuity throughout their healthcare journey. Choice A is incorrect as it focuses only on nursing care needs at discharge, which is just a part of the overall care needed. Choice C narrows down the focus to client education needs, excluding other essential care components. Choice D solely considers financial resources, neglecting the broader scope of care needs that a case manager is accountable for.