Nokea
Which action best demonstrates respect for autonomy when working with a client?
- A. Asks if the client has questions before signing a consent form
- B. Provides the client with accurate information when questioned
- C. Honors the promises made to the client and family
- D. Ensures fair treatment of the client compared to others
Correct Answer: A
Rationale: The correct answer is A because asking if the client has questions before signing a consent form shows respect for autonomy by allowing the client to make an informed decision. This action promotes the client's right to self-determination and involvement in the decision-making process. Choice B focuses on providing information when questioned but may not actively involve the client in the decision-making process. Choice C refers to honoring promises and not necessarily respecting autonomy. Choice D relates to fairness but does not directly address autonomy or the client's decision-making ability.
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The nurse is caring for a client with trigeminal neuralgia. To assist the client with nutrition needs, the nurse should:
- A. Offer small meals of high calorie soft food.
- B. Assist the client to sit in a chair for meals.
- C. Provide additional servings of fruits and raw vegetables.
- D. Encourage the client to eat fish, liver and chicken.
Correct Answer: A
Rationale: Soft foods minimize facial muscle movement, reducing pain.
A nurse is caring for a client post-myocardial infarction (MI). What is the priority assessment for this client?
- A. Monitoring urine output
- B. Checking blood glucose levels
- C. Assessing for chest pain
- D. Monitoring electrolyte levels
Correct Answer: C
Rationale: The correct answer is C: Assessing for chest pain. The priority assessment for a client post-MI is to monitor for any signs of recurrent chest pain or angina, as it could indicate ongoing cardiac ischemia or a new infarction. Prompt intervention is crucial in these situations to prevent further damage to the heart muscle. Monitoring urine output (A) and electrolyte levels (D) are important assessments but do not take precedence over assessing for chest pain. Checking blood glucose levels (B) is relevant for diabetic clients but is not the priority in this case.
In doing a nutritional assessment for Mrs. Collins who wants to lose weight, what should the nurse initially do?
- A. Ask her to describe her actual food intake and behaviors influencing eating
- B. Determine who does the cooking and shopping
- C. Determine what she knows about the basic four food groups
- D. Determine biochemical data such as urinalysis and blood chemistries
Correct Answer: A
Rationale: Understanding the patient's current eating habits and behaviors is crucial for tailoring an effective weight loss plan.
What best describes Mrs. West’s change in vital signs postoperatively?
- A. Decrease in BP indicates shock is imminent
- B. Elevated temperature indicates wound infection
- C. Decrease in BP is consistent with hypertension
- D. Elevation in temperature is consistent with normal postoperative recovery
Correct Answer: D
Rationale: A mild fever is common after surgery due to inflammatory response.
While on a hiking trip, Mr. Jones states that a branch of a tree struck his eye. Part of the branch remains lodged in the eye, and the eyelid is bleeding. Appropriate emergency treatment would include
- A. covering the eye with a protective shield
- B. encouraging Mr. Jones to hold his eye closed tightly
- C. applying a pressure dressing to the eye
- D. removing the foreign body and applying a sterile dressing
Correct Answer: A
Rationale: Covering the eye with a protective shield prevents further injury while awaiting professional medical evaluation and removal of the foreign object.