Nokea
Which factor is most likely to impact the body image of an infant newly diagnosed with Hemophilia?
- A. immobility
- B. altered growth and development
- C. hemarthrosis
- D. altered family processes
Correct Answer: D
Rationale: Rationale:
1. Altered family processes impact an infant's body image due to the emotional response and support provided by family members.
2. Positive family dynamics can help the infant cope with the diagnosis and build self-esteem.
3. Conversely, negative family processes may lead to feelings of inadequacy and affect body image.
4. Immobility, altered growth, and hemarthrosis are physical factors but do not directly influence body image.
Summary:
Altered family processes have the most significant impact on an infant's body image as they shape emotional support and self-perception. Immobility, altered growth, and hemarthrosis are important considerations but are not as directly related to body image in this context.
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What should the nurse do first when a client with a history of hypertension presents with severe headache?
- A. Administer pain relief
- B. Monitor vital signs
- C. Monitor ECG
- D. Administer insulin
Correct Answer: A
Rationale: The correct answer is A: Administer pain relief. The nurse should address the client's immediate symptom of severe headache to provide comfort and assess the severity of the condition. Pain relief can help decrease anxiety and prevent complications. Monitoring vital signs (B) is important but treating the symptom should take priority. Monitoring ECG (C) is not necessary for a headache presentation. Administering insulin (D) is not indicated for a client presenting with a severe headache.
What is the primary concern for a nurse caring for a client who is post-operative and experiencing confusion?
- A. Notify the healthcare provider
- B. Reorient the client
- C. Increase circulation
- D. Assess the level of pain
Correct Answer: B
Rationale: The correct answer is B: Reorient the client. Reorientation helps the confused client regain awareness of their surroundings, time, and situation post-operatively. It can improve their cognition and reduce anxiety. Notifying the healthcare provider (A) may be necessary but not the primary concern. Increasing circulation (C) is important but not the first step for a confused post-op client. Assessing pain (D) is important but addressing confusion takes precedence.
A nurse is teaching a patient with diabetes about managing diabetic neuropathy. Which of the following statements by the patient indicates the need for further education?
- A. I should inspect my feet daily for cuts or blisters.
- B. I can wear tight shoes to avoid blisters.
- C. I should avoid walking barefoot to prevent injuries.
- D. I should keep my blood glucose levels within the target range.
Correct Answer: B
Rationale: The correct answer is B: "I can wear tight shoes to avoid blisters." Tight shoes can increase pressure on the feet, leading to blisters and worsening neuropathy symptoms. A: Inspecting feet daily is important to catch any issues early. C: Walking barefoot can increase the risk of injuries. D: Maintaining blood glucose levels within target range is crucial for managing diabetic neuropathy. In summary, the incorrect choices either provide important preventive measures or focus on key aspects of diabetes management, while the correct choice suggests a harmful behavior that can exacerbate neuropathy symptoms.
Which of the following statements accurately describes the concept of culturally competent care?
- A. The health care provider is able to understand and speak the patient's mother tongue.
- B. The health care provider possesses a basic knowledge of the patient's cultural background.
- C. The health care provider has knowledge of the significance of social, economic, and cultural contexts.
- D. The health care provider applies knowledge, skills, attitudes, and personal attributes to maximize respect and care.
Correct Answer: D
Rationale: Step 1: Culturally competent care involves applying knowledge, skills, attitudes, and personal attributes to provide respectful and effective care.
Step 2: Understanding and speaking the patient's mother tongue (Option A) is important but not sufficient for culturally competent care.
Step 3: Possessing basic knowledge of the patient's cultural background (Option B) is helpful, but not comprehensive enough to ensure culturally competent care.
Step 4: Having knowledge of the significance of social, economic, and cultural contexts (Option C) is crucial but does not encompass the full scope of culturally competent care.
Step 5: The correct answer, D, encompasses the holistic approach needed for culturally competent care by emphasizing the application of knowledge, skills, attitudes, and personal attributes to maximize respect and care.
What is the most effective action when caring for a client who is at risk of developing pressure ulcers?
- A. Turn the client every two hours
- B. Increase the client's protein intake
- C. Encourage the client to rest
- D. Apply dressings to the wounds
Correct Answer: A
Rationale: The correct answer is A: Turn the client every two hours. This action helps prevent pressure ulcers by relieving pressure on specific areas of the body. Turning the client redistributes pressure, promotes circulation, and reduces the risk of tissue damage. It is a crucial part of pressure ulcer prevention in immobile or bedridden patients. Increasing protein intake (B) may aid in wound healing but does not directly prevent pressure ulcers. Encouraging rest (C) may not address the root cause of pressure ulcers. Applying dressings to wounds (D) is a treatment for existing ulcers, not prevention.