Nokea
Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter?
- A. Self-care deficit
- B. Functional incontinence
- C. Fluid volume deficit
- D. High risk for infection
Correct Answer: D
Rationale: The correct answer is 'High risk for infection.' When caring for a client with an indwelling urinary catheter, the highest priority is to prevent infections, as these catheters are a significant source of infection. Options A and B, self-care deficit and functional incontinence, may be concerns but are not directly related to the indwelling catheter. Option C, fluid volume deficit, is not typically associated with the presence of an indwelling urinary catheter.
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When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?
- A. Place the chair parallel to the bed, with its back toward the head of the bed, and assist the client in moving to the chair.
- B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair.
- C. Assist the client to a standing position by gently lifting upward from underneath the axillae.
- D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.
Correct Answer: B
Rationale: Option B is the correct procedure for assisting a client from the bed to a chair. By positioning the nurse's feet apart and aligning the knees with the client's knees, the nurse maintains a stable base of support while pivoting the client into the chair. This technique minimizes the risk of injury to both the nurse and the client. Placing the chair at a 45-degree angle to the bed, with the back of the chair toward the head of the bed, provides a clear path for the client to move. Option C is incorrect because lifting a client under the axillae can potentially cause nerve damage and strain. Option D is also incorrect as it involves an unsafe method of moving the client and can lead to injuries or accidents.
Which term refers to a comprehensive set of thoughts or images of oneself?
- A. Global self
- B. Core self-concept
- C. Personal identity
- D. Ideal self
Correct Answer: A
Rationale: The term 'Global self' specifically refers to a comprehensive set of thoughts or images about oneself. It encompasses a person's overall perception of themselves, including their beliefs, values, and self-image. 'Core self-concept' is more focused on the fundamental beliefs individuals hold about themselves, 'Personal identity' relates to the characteristics and qualities that distinguish a person from others, and 'Ideal self' represents the person an individual aspires to be rather than their current self-perception. Therefore, 'Global self' is the most appropriate term for the description provided in the question.
Which of the following is an example of passive aggression?
- A. Clenched fists
- B. Yelling
- C. Jealousy
- D. Intimidation
Correct Answer: C
Rationale: Passive aggression involves expressing negative feelings indirectly, such as through subtle actions or behaviors. While choices A, B, and D involve more direct and aggressive expressions of anger, jealousy is an example of passive aggression where negative emotions are subtly displayed without openly confronting the issue. Jealousy can manifest as resentment, envy, or possessiveness, and is a common form of passive aggression in interpersonal relationships.
Which action should the nurse implement when providing wound care instructions to a client who does not speak English?
- A. Ask an interpreter to provide wound care instructions.
- B. Speak directly to the client, with an interpreter translating.
- C. Request the accompanying family member to translate.
- D. Instruct a bilingual employee to read the instructions.
Correct Answer: B
Rationale: When providing wound care instructions to a client who does not speak English, the nurse should speak directly to the client with the assistance of an interpreter for accurate translation. The interpreter is trained to provide objective translations in the client's primary language, ensuring the client understands the instructions and can ask questions. Using family members for translation is discouraged as they may alter instructions or feel uncomfortable discussing certain topics. Instructing a bilingual employee to read the instructions is not ideal as they may lack the necessary training in accurate interpretation, which could lead to misunderstandings in crucial wound care instructions.
A client has been diagnosed with depression, and a nurse is assisting them. Which of the following is an example of a short-term outcome as part of the nursing process for this client?
- A. Client will verbalize that depression symptoms have lifted
- B. Client will identify life stressors that may be contributing to depression
- C. Client's insomnia will be resolved as evidenced by 8 hours of sleep each night
- D. Client will identify a mental health counselor in the community with whom they can meet for ongoing therapy
Correct Answer: B
Rationale: In the nursing process for a client with depression, short-term outcomes are goals that need to be achieved before advancing towards long-term outcomes. Identifying life stressors that may be contributing to the depression is a crucial initial step. This process helps the client work through feelings of grief or sadness before moving on to long-term goals like therapy and depression management.
Choice A is not a short-term outcome as the lifting of depression symptoms is usually a long-term goal. Choice C focuses on resolving insomnia, which is a symptom of depression, but not directly addressing the root cause. Choice D involves identifying a mental health counselor for ongoing therapy, which is more aligned with a long-term treatment plan, rather than a short-term outcome.