Nokea
For each assessment finding, click to specify if the finding is consistent with psychosis or mania.
- A. Hallucinations
- B. Lack of sleep
- C. Excessive spending habits
- D. Disorganized thought process
- E. Pressured speech
Correct Answer: A,B,C,D,E
Rationale: The correct answer is A, B, C, D, E. Hallucinations, lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are all consistent with both psychosis and mania. Hallucinations are sensory perceptions without a real external stimulus, common in both conditions. Lack of sleep is a hallmark symptom of mania and can also exacerbate psychotic symptoms. Excessive spending habits are often seen in manic episodes due to impulsivity, and disorganized thought process and pressured speech are characteristic of both psychosis and mania, reflecting the underlying cognitive and communication disturbances. Other choices are not specific or commonly associated with psychosis or mania.
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Which of the following findings indicate a positive test?
- A. An induration measuring 10 mm
- B. A reddened area with no induration
- C. An induration measuring 3 mm
- D. A blister at the injection site
Correct Answer: A
Rationale: The correct answer is A because an induration measuring 10 mm is considered positive for a tuberculin skin test, indicating exposure to tuberculosis. A larger induration size suggests a stronger immune response. Choice B, a reddened area with no induration, is not specific for a positive test. Choice C, an induration measuring 3 mm, is below the threshold for positivity. Choice D, a blister at the injection site, is a sign of irritation rather than a positive test result.
Which of the following instructions should the nurse include in the teaching?
- A. Take your temperature immediately after waking and before getting out of bed.
- B. Measure your temperature in the afternoon for the most accurate reading.
- C. A rise in body temperature of at least 2°F indicates ovulation has occurred.
- D. Use a standard digital thermometer for the most precise results.
Correct Answer: A
Rationale: The correct answer is A: Take your temperature immediately after waking and before getting out of bed. This instruction is part of basal body temperature monitoring for ovulation tracking. Body temperature is lowest upon waking and increases after ovulation, so taking the temperature before getting out of bed provides the most accurate baseline measurement. Choice B is incorrect because afternoon temperatures can fluctuate due to various factors. Choice C is incorrect as a rise of at least 0.4°F, not 2°F, indicates ovulation. Choice D is incorrect because a basal body temperature thermometer is more appropriate for this purpose than a standard digital thermometer.
Which of the following actions should the nurse take to promote learning?
- A. Speak loudly when addressing the client
- B. Connect new information with the client's past experiences
- C. Present the information to the client using abstract concepts
- D. Use a 12 point font when printing written material for the client
Correct Answer: B
Rationale: The correct answer is B: Connect new information with the client's past experiences. This promotes learning by linking new concepts to existing knowledge, aiding in retention and understanding. Speaking loudly (A) may not enhance learning and can be off-putting. Presenting information abstractly (C) may confuse the client. Using a 12 point font (D) is a formatting preference and does not directly impact learning.
Which of the following actions should the nurse include in the plan of care?
- A. Observe for bruising of the skin
- B. Provide a diet low in protein
- C. Monitor v/s every hour for the first 4 hr.
- D. Administer medications intramuscularly
Correct Answer: A
Rationale: The correct answer is A: Observe for bruising of the skin. This is important in assessing for potential complications such as bleeding disorders, which may indicate a need for further intervention. Providing a diet low in protein (B) is not relevant to the scenario unless specified. Monitoring vital signs every hour for the first 4 hours (C) may not be necessary unless there are specific concerns. Administering medications intramuscularly (D) is not indicated without further context.
Which intervention should the nurse include in the plan of care?
- A. Placing a formula in the container to last 18 hours
- B. Flushing the feeding tube with water every 4 to 6 hours.
- C. Covering and labeling the opened formula container with the date and time.
- D. Elevating the head of the bed to at least 30 degrees during feeding.
- E. Replacing the feeding container and tubing every 24 hours.
Correct Answer: E
Rationale: The correct answer is E, replacing the feeding container and tubing every 24 hours. This intervention is crucial to prevent bacterial contamination and ensure the patient's safety. By replacing the container and tubing regularly, the nurse helps maintain a sterile environment for the enteral feeding, reducing the risk of infection.
Choice A is incorrect because leaving formula in the container for 18 hours can lead to bacterial growth and contamination. Choice B, flushing the feeding tube with water every 4 to 6 hours, is important for tube patency but does not address the need for replacing the container and tubing. Choice C, covering and labeling the formula container, is a good practice for storage but does not address the need for regular replacement. Choice D, elevating the head of the bed during feeding, is important for preventing aspiration but is not directly related to the maintenance of feeding equipment.