Nokea
Which of the ff nursing actions is helpful for older clients who are experiencing lens changes associated with aging?
- A. Offering teaching aids with larged-sized letters
- B. Suggesting reduced visual activity such as reading or watching television
- C. Suggesting use of eye drops for comfort
- D. Suggesting use of glasses or contact lenses CARING FOR CLIENTS WITH EYE DISORDERS
Correct Answer: D
Rationale: The correct answer is D, suggesting the use of glasses or contact lenses. This is because as older clients experience lens changes associated with aging, they may develop presbyopia or other vision issues that can be corrected with corrective lenses. Glasses or contact lenses can help improve their vision and quality of life.
A, offering teaching aids with large-sized letters, may be helpful for clients with visual impairments but may not directly address the specific lens changes associated with aging.
B, suggesting reduced visual activity, is not beneficial as it may further limit the client's engagement in daily activities and social interactions.
C, suggesting the use of eye drops for comfort, may provide temporary relief for dry eyes but does not address the underlying lens changes affecting vision.
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The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using?
- A. Human Needs (Maslow) model
- B. Functional Health Patterns model
- C. Human Response Patterns model
- D. Body System model
Correct Answer: A
Rationale: The correct answer is A: Human Needs (Maslow) model. The nurse is using a systematic approach based on Maslow's Hierarchy of Needs, which includes physiological, safety, love/belonging, esteem, and self-actualization needs. This model organizes assessment data by prioritizing these universal life requirements.
Incorrect choices:
B: Functional Health Patterns model - This model focuses on 11 functional health patterns, not the hierarchy of universal life requirements.
C: Human Response Patterns model - This model focuses on the individual's response to stressors, not prioritizing universal life requirements.
D: Body System model - This model focuses on assessing specific body systems, not the holistic approach of addressing all life requirements.
Which food is recommended for the patient who must increase intake of potassium?
- A. Bread
- B. Potato
- C. Egg
- D. Cereal
Correct Answer: B
Rationale: The correct answer is B: Potato. Potatoes are high in potassium, which is essential for various bodily functions. Potatoes can help increase potassium intake in patients who require it. Bread, eggs, and cereal are not as rich in potassium as potatoes. Increasing intake of these foods won't provide the necessary boost in potassium levels needed for the patient.
A nursing intervention for anemia is:
- A. Medical therapy
- B. High protein, vitamin and iron diet
- C. Fluid therapy
- D. Chemotherapy
Correct Answer: B
Rationale: The correct answer is B, a high protein, vitamin, and iron diet, as it directly addresses the nutritional deficiencies associated with anemia. Proteins aid in the production of red blood cells, while iron and vitamins are essential for hemoglobin synthesis. Medical therapy (A) typically involves medications or blood transfusions, not dietary changes. Fluid therapy (C) may be used for certain types of anemia, but it is not a primary intervention. Chemotherapy (D) is not indicated for the treatment of anemia, as it is used for cancer treatment. Therefore, choice B is the most appropriate intervention for anemia.
What is the nurse’s primary legal responsibility when implementing nursing interventions?
- A. Ensure client safety
- B. Follow physician orders precisely
- C. Document care comprehensively
- D. Provide client-centered education
Correct Answer: A
Rationale: The correct answer is A: Ensure client safety. This is the nurse's primary legal responsibility as it aligns with the ethical principle of beneficence, prioritizing the well-being and safety of the client. Ensuring client safety is essential to prevent harm and promote positive health outcomes. Following physician orders precisely (B) is important but not the primary legal responsibility of the nurse. Documenting care comprehensively (C) is crucial for accountability and continuity of care but is not the primary legal responsibility. Providing client-centered education (D) is essential for empowering clients but is not the primary legal responsibility in terms of legal accountability and duty of care.
Emil, just had a thyroidectomy this morning. Upon awakening, he complains of circumoral tingling, has a positive Chvostek’s sign and positive Trousseau’s sign. Nurse Ofel assesses this to be an indication of:
- A. Overstimulation of the parathyroid hormone
- B. Insufficient iodine intake
- C. inadvertent removal of the parathyroid
- D. Overuse of radioactive iodine gland
Correct Answer: A
Rationale: Rationale: The correct answer is A, overstimulation of the parathyroid hormone. After a thyroidectomy, there is a risk of unintentional damage to the parathyroid glands, leading to hypoparathyroidism. Circumoral tingling, positive Chvostek’s sign, and positive Trousseau’s sign are classic signs of hypocalcemia resulting from parathyroid insufficiency. Choices B, C, and D are incorrect because they do not explain the specific symptoms observed in Emil, which are indicative of low calcium levels due to parathyroid dysfunction.