Nokea
Which of the following actions should the nurse take to use a wide base support when assisting a client to get up in a chair?
- A. Bend at the waist and place arms under the client's arms and lift
- B. Face the client, bend knees and place hands on client's forearm and lift
- C. Spread his or her feet apart
- D. Tighten his or her pelvic muscles
Correct Answer: B
Rationale: Facing the client, bending knees, and using forearms provides a wide base and proper body mechanics for safe lifting.
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Roger has been seen agitated, shouting and running. As Nurse Aida approaches, he shouts and swear, calling Aida names. Nurse Aida told Roger 'That is an unacceptable behavior Roger, Stop and go to your room now.' The situation is most likely in what phase of NPR?
- A. Pre Orientation
- B. Orientation
- C. Working
- D. Termination
Correct Answer: C
Rationale: This scenario fits the Working phase (C). Roger's agitation and Aida's response setting boundaries suggest an established relationship where interventions address behaviors. Pre-Orientation (A) is pre-contact, Orientation (B) builds trust, not confrontation, and Termination (D) ends care. In Peplau's Working phase, the nurse actively helps the client manage issues, as Aida does here, making C the likely phase.
The nurse gave Mr. Gary his medication as planned. This is an example of?
- A. Implementation
- B. Planning
- C. Evaluation
- D. Assessment
Correct Answer: A
Rationale: Giving medication as planned is implementation (A) executing care, per process. Planning (B) sets, evaluation (C) assesses, assessment (D) gathers not action-specific. A fits intervention delivery, 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.
A theory is a set of concepts, definitions, relationships and assumptions that:
- A. Explain a phenomenon
- B. Formulate legislation
- C. Measure nursing functions
- D. Reflect the domain of nursing practice
Correct Answer: A
Rationale: A theory e.g., Henderson's uses concepts (e.g., breathing), definitions (clarifying terms), relationships (how needs interact), and assumptions (e.g., patients seek independence) to explain phenomena like recovery. This informs nursing actions e.g., why positioning aids breathing. Formulating legislation is policy, not theory's role indirectly influenced. Measuring functions suits research, not theory's explanatory purpose. Reflecting the domain describes scope, not function explanation is active. Theories explain health-related events, providing nurses frameworks to understand and address client needs, making this the precise definition.
Which of the following statement is NOT true about cultural competence in nursing?
- A. Respects diversity
- B. Improves care
- C. Forces assimilation
- D. Adapts to patient needs
Correct Answer: C
Rationale: Cultural competence respects diversity (A), improves care (B), adapts (D) 'forces assimilation' (C) isn't true, opposes respect, per standards. C's coercion contradicts competence, like with Mr. Gary's beliefs, making it untrue.