Nokea
Which is the best way to position a client's neck for palpation of the thyroid?
- A. flexed toward the side being examined
- B. hyperextended directly backward
- C. flexed away from the side being examined
- D. flexed directly forward
Correct Answer: A
Rationale: Flexing the neck toward the side being examined relaxes the sternocleidomastoid muscle, making the thyroid gland more accessible for palpation.
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When documenting in the client's record, what type of information should be recorded?
- A. educated predictions of outcomes
- B. personal opinions
- C. objective information
- D. subjective information
Correct Answer: C
Rationale: Objective, factual information should be recorded in the client's chart.
A nurse witnesses a client sign the consent form for surgery with the surgeon. As the surgeon leaves, the client starts to speak and then stops. The nurse asks if the client has further questions and he says, 'I don't want to bother the surgeon.' The nurse should
- A. acknowledge the client's wish not to bother the surgeon and tell the client to let you know if they change their mind
- B. acknowledge the client's wish not to bother the surgeon and answer all of their questions, as appropriate
- C. go get the surgeon to answer all of the client's questions
- D. answer any questions as appropriate as well as have the surgeon come back to answer any questions if needed
Correct Answer: D
Rationale: Nurses should always advocate for their clients, making sure they understand everything involving their health as well as ensuring all questions are answered appropriately and thoroughly.
A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, 'I do not know how to make my diet work with the kind of foods that my family eats.' What should the nurse do first to help the client determine a suitable diet for disease prevention?
- A. Provide her with copies of the approved dietary guidelines for the American Diabetic Association and the American Heart Association.
- B. Ask the client to provide a list of the types of foods she eats to determine how to best meet her needs.
- C. Provide a high-protein diet plan for the client.
- D. Provide the client with information related to risk factors for heart disease and diabetes.
Correct Answer: B
Rationale: Assessment is the first step. Assessing what the client eats helps the nurse determine a plan for dietary recommendations based on the ADA and AHA guidelines. Providing the client with a copy of the guidelines is important but is not the first priority. Based on the client's wish to reduce her chances of heart disease and diabetes, a high-protein diet plan might not be appropriate. Providing information to the client related to risk factors for heart disease and diabetes is important but is not the first step.
To manage time most effectively, the nurse responds to which of the following stimuli first:
- A. the physician's loud verbal direction.
- B. the nursing supervisor who is going to a meeting.
- C. unit staff leaving on a break.
- D. the care needs of the returning postoperative client just exiting the elevator.
Correct Answer: D
Rationale: While many environmental stimuli might compete for attention and time, the client care needs of complex or unstable clients and those requiring assessment and care must take priority.
Which of the following provides the framework for confidentiality and the client's right to privacy?
- A. Health Insurance Portability and Accountability Act
- B. CDC Surveillance Programs
- C. American Nurses Association Code of Ethics
- D. durable power of attorney for health care
Correct Answer: A
Rationale: HIPAA is the federal statute that outlines client confidentiality and the client's right to privacy.