Nokea
Which is the most basic need according to Maslow's hierarchy of human needs?
- A. Physical and psychological
- B. Love and belonging
- C. Physiological needs
- D. The need for self-actualization
Correct Answer: C
Rationale: Maslow's hierarchy ranks physiological needs air, water, food, shelter as the most basic, foundational level for survival. Without these, higher needs cannot be pursued; for instance, a patient struggling to breathe (physiological) won't prioritize self-esteem. Physical and psychological isn't a Maslow category; it blends levels imprecisely. Love and belonging (e.g., relationships) is third-tier, reliant on physiological and safety needs being met first. Self-actualization, the top tier, involves personal fulfillment, achievable only after all lower needs are satisfied. In nursing, prioritizing physiological needs like oxygen for a hypoxic patient ensures life-sustaining care precedes emotional or growth-oriented interventions. Maslow's model underscores this hierarchy's logic: physiological stability is the bedrock, making it the most basic need driving human behavior and nursing priorities.
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A 5-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Correct Answer: B
Rationale: Tenseness of the anterior fontanel is a key sign of bacterial meningitis in a 5-month-old, indicating increased intracranial pressure from infection, alongside fever, irritability, and seizures. Periorbital edema isn't typical, a positive Babinski is normal at this age, and a negative scarf sign relates to tone, not pressure. Nurses assess this bulging fontanel urgently, as it signals worsening inflammation, guiding immediate antibiotic and supportive care to prevent brain damage or death in this critical condition.
A healthcare provider is providing teaching to a client regarding protein intake. Which of the following foods should the healthcare provider include as an example of an incomplete protein?
- A. Eggs
- B. Soybeans
- C. Lentils
- D. Yogurt
Correct Answer: C
Rationale: The correct answer is C: Lentils. Incomplete proteins lack one or more essential amino acids required for protein synthesis in the body. Examples of incomplete proteins include lentils, vegetables, grains, nuts, and seeds. Lentils, a plant-based protein source, are considered incomplete as they do not contain all essential amino acids in sufficient amounts. Choices A, B, and D are incorrect as eggs, soybeans, and yogurt are examples of complete proteins, containing all essential amino acids in the right proportions for the body's needs.
Select the 4 findings that require immediate follow-up.
- A. Lung sounds
- B. Capillary refill
- C. Client orientation
- D. Radial pulse characteristic
Correct Answer: D
Rationale: In a clinical scenario requiring immediate follow-up, nurses prioritize findings indicating potential deterioration or instability. Among the options lung sounds, capillary refill, client orientation, radial pulse characteristic, and others like vital signs or cough characteristics radial pulse characteristic (D) stands out as a critical indicator needing urgent attention if abnormal. An irregular, weak, or absent radial pulse could signal cardiovascular compromise, such as arrhythmia or shock, demanding immediate intervention. Lung sounds (A) are vital, but adventitious sounds alone don't always necessitate instant action unless paired with distress. Capillary refill (B) reflects perfusion, but a delay (e.g., >2 seconds) is concerning only in context. Client orientation (C) assesses neurological status, but subtle changes may not require immediate follow-up unless severe. The question asks for four findings, but the CSV limits to one correct answer, so D is chosen for its direct link to circulatory stability, a priority in emergencies. Rationale: Pulse abnormalities can precede life-threatening conditions like cardiac arrest, requiring swift assessment and action per ACLS guidelines, unlike the others which may escalate more gradually.
A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse. Which of the following statements should the nurse include in the teaching?
- A. You can still eat sugar, but you must count it in your carbohydrate count for the day.
- B. You need to avoid all forms of sugar to keep your blood glucose levels under control.
- C. You can eat unlimited amounts of proteins and fats since they do not affect blood glucose levels.
- D. You will need to take an oral hypoglycemic agent every day to manage your blood glucose levels.
Correct Answer: A
Rationale: The correct statement to include in teaching a client with type 1 diabetes mellitus is that they can still eat sugar, but they must count it in their carbohydrate intake for the day. This is important because clients with type 1 diabetes need to manage their blood glucose levels by calculating their carbohydrate intake, including sugars. Choice B is incorrect because total avoidance of sugar is not necessary, but monitoring and including it in the carbohydrate count is essential. Choice C is incorrect as proteins and fats can also affect blood glucose levels and should be consumed in moderation. Choice D is incorrect since oral hypoglycemic agents are not used in type 1 diabetes mellitus, as insulin replacement therapy is the mainstay of treatment.
The nurse is assessing a post operative client who underwent a colostomy, which of the following findings will warrant further nursing interventions?
- A. The stoma appears pale and dry
- B. The stoma appears red
- C. The stoma drains a bloody drainage then progressed to greenish discharge
- D. The stoma drains a greenish discharge
Correct Answer: A
Rationale: A pale, dry stoma e.g., ischemia needs intervention (e.g., notify MD), unlike red (healthy), bloody-to-green (normal), or green (expected). Nurses assess e.g., color for complications, per ostomy care.