Nokea
Which of the following describes a 'comfort zone'?
- A. The area where closeness is not required during nursing care.
- B. The area that encompasses up to 5 to 7 feet from the client.
- C. The area that,when intruded upon does not create any kind of anxiety.
- D. The area where a client is well draped.
Correct Answer: B
Rationale: A comfort zone typically refers to the personal space around an individual, which varies but generally extends up to 5-7 feet.
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In assigning patients with alterations related to gastrointestinal (GI) cancer, which would be the most appropriate nursing care tasks to assign to the LPN/LVN, under supervision of the team leader RN?
- A. A patient with severe anemia secondary to GI bleeding.
- B. A patient who needs enemas and antibiotics to control GI bacteria.
- C. A patient who needs pre-op teaching for bowel resection surgery.
- D. A patient who needs central line insertion for chemotherapy.
Correct Answer: B
Rationale: Administering enemas and antibiotics involves routine tasks that LPNs/LVNs are trained to perform, whereas the other options require advanced skills or supervision.
While caring for an unconscious patient, the nurse discovers a stage 2 pressure ulcer on the patient’s heel. During care of the ulcer, what is the nurse’s understanding of the patient’s perception of pain?
- A. The patient will have a behavioral response if pain is perceived.
- B. The area should be treated as a painful lesion, using gentle cleansing and dressing.
- C. The area can be thoroughly scrubbed because the patient is not able to perceive pain.
- D. All nociceptive stimuli that are transmitted to the brain result in the perception of pain.
Correct Answer: B
Rationale: The correct answer is B. Even in unconscious patients, the area should be treated gently to avoid exacerbating potential pain.
Mrs. Williams asks what “presbyopia†means. The best response would be that Mrs. Williams
- A. is 'farsighted' and can see well at a distance, but her near vision is poor
- B. is 'nearsighted' and can see well when objects are close but cannot see well at a distance
- C. has distorted vision which is caused by a curvature in the eye
- D. has difficulty seeing objects that are very close because her lens is less elastic
Correct Answer: D
Rationale: Presbyopia results from decreased elasticity of the eye's lens, impairing the ability to focus on nearby objects, typically occurring with age.
What goal assumes the highest priority for Ms. Weeze with an acute asthmatic attack?
- A. Preventing future attacks
- B. Maintaining quiet, restful environment
- C. Observing for signs of drug toxicity
- D. Relieving bronchial spasm
Correct Answer: D
Rationale: Relieving bronchospasm is critical to restore adequate airflow.
Patient teaching for risk reduction of skin cancer should include
- A. Having suspicious moles checked by a dermatologist.
- B. Daily sun exposure every 1/2 hour.
- C. Daily sun exposure of 1 hour to build tolerance.
- D. Applying moisturizer.
Correct Answer: A
Rationale: Regular monitoring of moles and avoiding excessive sun exposure are vital for skin cancer prevention.