Nokea
Which intervention is important in preventing pressure ulcers in immobilized patients?
- A. Frequent repositioning
- B. Encouraging immobility
- C. Maintaining prolonged periods of immobility
- D. Applying tight dressings over bony prominences
Correct Answer: A
Rationale: Frequent repositioning prevents pressure ulcers in immobilized patients by relieving pressure on skin over bones, boosting circulation, and reducing tissue breakdown risk. Sustaining or promoting immobility heightens this risk, as does tight dressings that add pressure and impair blood flow. Nurses implement this intervention shifting positions every two hours, for instance to protect skin integrity, a fundamental strategy in caring for those unable to move independently, prioritizing prevention over reactive treatment.
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After a head injury, a client develops a deficiency of antidiuretic hormone (ADH). What should the nurse consider before assessing the patient about the response to secretion of ADH?
- A. Serum osmolality increases
- B. Urine concentration decreases
- C. Glomerular filtration decreases
- D. Tubular reabsorption of water increases
Correct Answer: B
Rationale: ADH deficiency (diabetes insipidus) post-head injury causes dilute urine (B) due to reduced water reabsorption. Osmolality increases (A) is a result, not a cause. GFR (C) isn't primarily affected. Reabsorption (D) decreases. B is correct. Rationale: Low ADH leads to polyuria with low urine concentration, a key assessment in DI, per endocrine trauma care.
An eleven-month-old infant is brought to the pediatric clinic. The nurse suspects that the child has iron deficiency anemia. Because iron deficiency anemia is suspected, which of the following is the most important information to obtain from the infant's parents?
- A. Normal dietary intake
- B. Relevant socio cultural, economic, and educational background of the family
- C. Any evidence of blood in the stools
- D. A history of maternal anemia during pregnancy
Correct Answer: A
Rationale: Dietary intake reveals iron sources, critical for diagnosing deficiency.
A client has a Staphylococcus infection in a decubitus ulcer. In this case, Staphylococcus is the:
- A. Host
- B. Agent
- C. Environment
- D. Disease
Correct Answer: B
Rationale: In the Agent-Host-Environment Model, Staphylococcus is the agent the causative factor triggering illness, here infecting a decubitus ulcer. The client is the host, whose skin integrity and immunity determine susceptibility. The environment bedridden conditions or hygiene sets the stage for infection. The disease is the resulting pathology, like the ulcer's worsening. This model dissects causation: Staphylococcus (bacteria) invades the host (client) in a conducive environment (immobility), driving nursing interventions cleaning wounds, repositioning to disrupt the triad. Understanding the agent's role guides targeted care, like antibiotics, breaking the infection cycle. It's a practical lens for nurses, pinpointing external triggers to prevent or manage illness effectively, especially in chronic wound scenarios.
The nurse asked an aide to check Mr. Gary's vitals. This is an example of?
- A. Delegation
- B. Responsibility
- C. Malpractice
- D. Health policy
Correct Answer: A
Rationale: Asking an aide for vitals is delegation (A) task assignment, per definition. Responsibility (B) duty, malpractice (C) breach, policy (D) rules not delegation-specific. A fits the nurse's supervised task for Mr. Gary, making it correct.
The nurse is preparing a client with gout for discharge. Which dietary selection reflects an understanding of the client's condition?
- A. Broiled chicken, rice, and iced tea
- B. Sardines, lima beans, and red wine
- C. Hamburger, fries, and a milkshake
- D. Shrimp, spinach, and beer
Correct Answer: A
Rationale: Broiled chicken, rice, and iced tea suit gout, avoiding purine-rich foods (sardines, shrimp) or alcohol (wine, beer) that raise uric acid lima beans and spinach also contribute less but aren't ideal. Nurses teach this, reducing flare-ups, supporting joint health and client compliance.