Nokea
Which action best demonstrates the nurse’s role in ensuring continuity of care during the evaluation phase?
- A. Rewriting the care plan based on current findings.
- B. Communicating the client’s progress to the interdisciplinary team.
- C. Reassessing the client to gather additional data.
- D. Providing emotional support to the client and family.
Correct Answer: B
Rationale: The correct answer is B: Communicating the client’s progress to the interdisciplinary team. During the evaluation phase, the nurse plays a crucial role in ensuring continuity of care by effectively communicating the client’s progress to the interdisciplinary team. This action allows for collaborative decision-making based on the latest information, promotes coordination of care, and ensures that all team members are informed and involved in the client's care plan. Rewriting the care plan (A) is important but may not be the most immediate action during the evaluation phase. Reassessing the client (C) is valuable for gathering additional data but may not directly contribute to continuity of care during this phase. Providing emotional support (D) is essential but may not specifically address continuity of care during evaluation.
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When assessing a client with a disorder of the hematopoietic or the lymphatic, why is it important for the nurse to obtain a dietary history?
- A. Compromised nutrition interferes with the production of blood cells and hemoglobin
- B. Diet consisting of excessive fat interferes with the production of blood cells and haemoglobin
- C. Inconsistent dieting interferes with the production of blood cells and haemoglobin
- D. Diet consisting of excessive iron and protein elements interferes with the production of blood cells and haemoglobin
Correct Answer: A
Rationale: The correct answer is A because compromised nutrition can lead to deficiencies in essential nutrients required for the production of blood cells and hemoglobin. Iron, vitamins, and minerals obtained from food are crucial for erythropoiesis and maintaining a healthy immune system. Without these nutrients, the body may struggle to produce an adequate amount of healthy red blood cells, leading to anemia and compromised immune function.
Choice B is incorrect because excessive fat in the diet is not directly linked to interfering with the production of blood cells and hemoglobin. Choice C is incorrect as inconsistent dieting may affect overall health but is not specifically related to hematopoiesis. Choice D is incorrect because while iron and protein are important for blood cell production, excessive amounts of these elements are unlikely to interfere with the production of blood cells and hemoglobin.
A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
- A. The nurse makes eye contact with the patient.
- B. The nurse speaks only to the patient’s daughter.
- C. The nurse leans forward while talking with the patient.
- D. The nurse nods periodically while the patient is speaking.
Correct Answer: B
Rationale: The correct answer is B because the nurse should primarily communicate with the patient, not just the daughter. This ensures patient-centered care and respects the patient's autonomy. Speaking only to the daughter may undermine the patient's dignity and may lead to incomplete information gathering. Choices A, C, and D are incorrect as they are appropriate nursing communication techniques that facilitate rapport-building and active listening with the patient. Making eye contact, leaning forward, and nodding are all positive non-verbal cues that show engagement and attentiveness to the patient, promoting effective communication and building trust.
Before, during and after seizure. The nurse knows that the patient is ALWAYS placed in what position?
- A. Low fowler’s
- B. Modified trendelenburg
- C. Side lying
- D. Supine NERVOUS SYSTEM
Correct Answer: C
Rationale: The correct answer is C: Side lying position. This position helps prevent aspiration of secretions and promotes drainage from the mouth during and after a seizure. Placing the patient in a side lying position also helps prevent injury from falling and facilitates monitoring of the patient's airway.
Incorrect choices:
A: Low fowler's - This position does not provide optimal airway protection and may increase the risk of aspiration during a seizure.
B: Modified trendelenburg - This position may worsen the patient's airway patency and does not facilitate drainage of secretions.
D: Supine - Placing the patient in a supine position can lead to aspiration and compromise the airway, especially during a seizure.
Summary: The side lying position is the most appropriate choice as it ensures airway protection, facilitates drainage, and reduces the risk of aspiration during and after a seizure.
Antimetabolites are a diverse group of antineoplastic agents that interfere with various metabolic actions of the cell. The mechanism of action of antimetabolites interferes with:
- A. Cell division or mitosis during the M phase of the cell cycle.
- B. Normal cellular processes during the S phase of the cell cycle.
- C. The chemical structure of deoxyribonucleic acid (DNA) and chemical binding between DNA molecules (cell cycle-nonspecific).
- D. One or more stages of ribonucleic acid (RNA) synthesis, DNA synthesis, or both (cell cycle- nonspecific).
Correct Answer: D
Rationale: The correct answer is D because antimetabolites interfere with the synthesis of nucleic acids (RNA and/or DNA), affecting multiple stages of RNA and DNA synthesis. This disruption hinders cell division and leads to cell death. Choices A and B are incorrect because antimetabolites do not specifically target cell division during the M phase or normal cellular processes during the S phase. Choice C is also incorrect because antimetabolites primarily target nucleic acid synthesis rather than altering the chemical structure of DNA or the binding between DNA molecules.
Correct method of mouth to mouth respiration is that the victim’s chin is held:
- A. Forward
- B. Backward
- C. Sideward
- D. Downward
Correct Answer: D
Rationale: The correct answer is D (Downward) because it helps to maintain a clear airway for effective mouth-to-mouth respiration. By holding the victim's chin downward, you can ensure proper alignment of the airway, allowing the tongue to fall forward and prevent obstruction. Holding the chin forward (Choice A) may cause the airway to close, holding it backward (Choice B) may strain the neck, and holding it sideward (Choice C) may not provide optimal airway alignment. Holding the chin downward is the most effective and safe method for providing mouth-to-mouth respiration.