Nokea
Which of the following activities on the part of the nurse most demonstrates individualization of the nursing-care plan for a client?
- A. Include client's preferred times of care and methods used.
- B. Write the care plan instead of taking it off the computer.
- C. Use a care plan from a book but add some things to it.
- D. Select nursing diagnoses that match the client's problems
Correct Answer: A
Rationale: Individualizing a care plan is best shown by including the client's preferred times and methods, tailoring care to their unique needs and lifestyle. For instance, scheduling baths when a client feels most rested respects their routine, enhancing comfort and compliance. Writing plans manually or adapting generic ones lacks this personal touch, while matching diagnoses is standard, not individualized. This approach reflects client-centered care, ensuring interventions like wound care timing fit the individual, boosting effectiveness and satisfaction.
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The coronary vessels, unlike any other blood vessels in the body, respond to sympathetic stimulation by
- A. Vasoconstriction
- B. Vasodilatation
- C. Decreases force of contractility
- D. Decreases cardiac output
Correct Answer: B
Rationale: The coronary vessels are unique because they respond to sympathetic stimulation with vasodilatation, unlike most other blood vessels which constrict. Sympathetic stimulation activates the fight-or-flight response, increasing heart rate and oxygen demand. To meet this demand, the coronary arteries dilate to supply more blood to the heart muscle. Vasoconstriction (A) is incorrect as it would reduce blood flow, countering the heart's needs during stress. Decreases in force of contractility (C) or cardiac output (D) are unrelated to the vascular response and pertain more to myocardial function, not the coronary vessels' behavior. This vasodilatation is mediated by beta-adrenergic receptors, ensuring adequate perfusion during heightened activity, making B the correct choice.
A patient develops red eyes 2 days after an episode of malaria probable cause is:
- A. Conjunctivitis
- B. Anterior uveitis
- C. Viral keratitis
- D. Endophthalmitis
Correct Answer: B
Rationale: Red eyes post-malaria suggest an ocular complication. Conjunctivitis (choice A) causes redness but isn't typically linked to malaria unless secondary infection occurs. Anterior uveitis (choice B), inflammation of the iris and ciliary body, is a rare but documented malaria sequel, possibly from immune response or parasite-related damage, presenting with redness, pain, and photophobia. Viral keratitis (choice C) affects the cornea and is unrelated to malaria. Endophthalmitis (choice D), a severe intraocular infection, is unlikely without trauma or surgery. B is correct, as anterior uveitis aligns with malaria's systemic inflammatory effects. Nurses should assess eye symptoms, refer to ophthalmology, and manage pain, preventing vision loss in such cases.
Which of the following urine color is considered normal?
- A. Dark amber
- B. Yellow, Cloudy
- C. Light Yellow, Amber
- D. Slightly pale yellow
Correct Answer: D
Rationale: Slightly pale yellow is normal e.g., hydrated urine per standards. Dark amber (dehydration), yellow cloudy (infection), light yellow amber (concentrated) differ. Nurses assess e.g., hydration for health, per norms.
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.
The nurse notes small, pimple-like pustules all over the newborn's body. When charting the integumentary assessment of this newborn, which normal finding does the nurse note?
- A. Strawberry hemangiomas
- B. Port-wine stain
- C. Erythema toxicum
- D. Telangiectatic nevi simplex
Correct Answer: C
Rationale: Small, pimple-like pustules on a newborn's body suggest erythema toxicum (C), a benign, self-limiting rash common in the first week of life, often with erythematous macules and pustules. Strawberry hemangiomas (A) are vascular growths, not pustular. Port-wine stains (B) are flat, purple birthmarks. Telangiectatic nevi simplex (D) are salmon-colored patches, not pustules. C is correct. Rationale: Erythema toxicum affects up to 70% of newborns, caused by an immune response, resolving without treatment, distinct from vascular or permanent lesions, aligning with normal neonatal skin findings.