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When recording blood pressure, the sounds which can be heard with a stethoscope placed over the artery is termed as:
- A. Wheeze
- B. Murmurs
- C. Crackle sounds
- D. Korotkoff sounds
Correct Answer: D
Rationale: Blood pressure measurement involves listening to arterial sounds via a stethoscope as the cuff deflates. These sounds, known as Korotkoff sounds, occur in five phases, starting with a tapping (systolic pressure) and fading to silence (diastolic pressure). Wheezes are respiratory sounds, murmurs relate to heart valves, and crackles indicate lung fluid none apply to blood pressure. Named after Nikolai Korotkoff, these sounds are a cornerstone of manual blood pressure assessment, ensuring accurate readings essential for diagnosing hypertension or hypotension, reflecting cardiovascular health.
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Which of the following nursing intervention is needed before teaching a client post spleenectomy deep breathing and coughing exercises?
- A. Tell the patient that deep breathing and coughing exercises is needed to promote good breathing, circulation and prevent complication
- B. Tell the client that deep breathing and coughing exercises is needed to prevent Thrombophlebitis, hydrostatic pneumonia and atelectasis
- C. Medicate client for pain
- D. Tell client that cooperation is vital to improve recovery
Correct Answer: C
Rationale: Medicating for pain (C) is needed before teaching post-splenectomy exercises; pain hinders participation, per nursing care. General benefits (A), specific risks (B), and cooperation (D) follow pain control. C ensures effective learning, making it correct.
Which psychological effect is commonly observed in patients experiencing immobility?
- A. Increased motivation
- B. Decreased risk of depression
- C. Increased sense of independence
- D. Increased risk of anxiety and depression
Correct Answer: D
Rationale: Immobility often increases anxiety and depression risk, as patients face mobility loss, dependence, and isolation, fostering psychological distress. Motivation and independence typically wane with restricted activity, while depression risk rises, not falls, due to these constraints. Nurses address this through emotional support and engagement, understanding that mental health declines when physical freedom is curtailed. This effect highlights the need for holistic care, blending physical interventions with psychological support to mitigate the emotional toll of immobility on patients.
As a nurse manager, which of the following best describes this function?
- A. Initiate modification on client's lifestyle
- B. Protect client's right
- C. Coordinates the activities of other members of the health team in managing patient care
- D. Provide in service education programs, Use accurate nursing audit, formulate philosophy and vision of the institution
Correct Answer: D
Rationale: A nurse manager's role encompasses planning (vision formulation), organizing (team coordination), directing (training), and controlling (audits), per management theories like Venzon's. This holistic function e.g., setting care standards, training staff, evaluating outcomes ensures quality across a unit, unlike narrower roles like lifestyle change (change agent), rights protection (advocate), or team coordination (case manager). It's a strategic position driving institutional excellence, pivotal in healthcare leadership.
The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma?
- A. 6
- B. 9
- C. 12
- D. 15
Correct Answer: A
Rationale: A Glasgow Coma Scale (GCS) score of 6 (A) indicates coma, defined as ≤8, reflecting minimal responsiveness (eye, verbal, motor). Scores of 9 (B) and 12 (C) suggest moderate injury. 15 (D) is normal. A is correct. Rationale: GCS ≤8 signifies severe brain dysfunction, often requiring intubation, a standard threshold in neurocritical care for coma classification and management.
When a client wishes to improve the appearance of their eyes by removing excess skin from the face and neck, the nurse should provide teaching regarding which of the following procedures?
- A. Dermabrasion
- B. Rhinoplasty
- C. Blepharoplasty
- D. Rhytidectomy
Correct Answer: D
Rationale: Rhytidectomy (facelift) removes excess skin from face and neck.