Nokea
Which of the following is considered an internal disaster?
- A. A patient fall
- B. The massive spread of pneumonia
- C. A computer hacking episode
- D. Unexpected staff absences due to illness
Correct Answer: C
Rationale: A computer hacking episode is considered an internal disaster as it disrupts the internal operations of the healthcare facility, compromising data security and potentially impacting patient care. Choices A, B, and D do not directly relate to internal disasters in a healthcare setting. A patient fall is a patient safety issue, the massive spread of pneumonia is a public health concern, and unexpected staff absences due to illness may affect staffing levels but are not typically classified as internal disasters.
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Select all of the risk factors that are associated with deep vein thrombosis.
- A. The use of oral contraceptives
- B. Type B and O blood
- C. Rh negative blood
- D. Underweight
Correct Answer: A
Rationale: The correct answer is A: "The use of oral contraceptives." Risk factors for deep vein thrombosis include factors such as immobility, surgery, cancer, obesity, smoking, and the use of oral contraceptives. Choices B, C, and D are incorrect because blood type and Rh factor do not play a role in the development of deep vein thrombosis, and being underweight is not typically considered a risk factor for this condition.
You are performing a neurological assessment of your adolescent patient. The patient has the Moro reflex. How should you interpret this neurological assessment finding?
- A. It is normal among adolescents.
- B. It indicates that the patient has an intact peripheral nervous system.
- C. It indicates that the patient has an intact central nervous system.
- D. It is not a normal finding.
Correct Answer: D
Rationale: The Moro reflex, also known as the startle reflex, is typically present in infants up to around 4-6 months of age and is characterized by the infant's response to a sudden loss of support or loud noise. It is not a normal finding in adolescents or older individuals. Therefore, if an adolescent patient exhibits the Moro reflex during a neurological assessment, it is considered abnormal and warrants further evaluation. Choices A, B, and C are incorrect because the Moro reflex is not expected or normal among adolescents and does not specifically indicate the status of either the peripheral or central nervous system in this age group.
What are the six levels of consciousness from the most to the least responsive level of consciousness? Number all six using 1 as the most conscious and 6 as the least conscious.
- A. Obtunded, Confused, Lethargic, Comatose, Stuporous, Alert
- B. Confused, Lethargic, Obtunded, Stuporous, Comatose, Alert
- C. Lethargic, Obtunded, Confused, Stuporous, Comatose, Alert
- D. Alert, Confused, Lethargic, Obtunded, Stuporous, Comatose
Correct Answer: D
Rationale: The correct order of the six levels of consciousness from most to least responsive is Alert, Confused, Lethargic, Obtunded, Stuporous, Comatose. Choice A is incorrect because it starts with Obtunded, which is less responsive than Alert. Choice B is incorrect as it doesn't follow the correct order. Choice C is incorrect as Lethargic is more responsive than Obtunded. Therefore, the correct answer is D.
A nurse is supervising an assistive personnel (AP) who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?
- A. Elevating the head of the client's bed to 30 degrees during mealtime
- B. Withholding fluids until the end of the meal
- C. Providing a 10-minute rest period prior to meals
- D. Instructing the client to place her chin toward her chest when swallowing
Correct Answer: D
Rationale: The correct technique for a client with dysphagia is to instruct them to place their chin toward their chest when swallowing. This action helps to close off the airway during swallowing, reducing the risk of aspiration. Elevating the head of the client's bed to 30 degrees during mealtime helps prevent aspiration, but this is not the responsibility of the AP. Withholding fluids until the end of the meal can lead to dehydration and is not a recommended practice. Providing a 10-minute rest period prior to meals is not specifically related to improving swallowing safety for clients with dysphagia.
A client with diabetes experiences Somogyi's effect. To prevent this complication, the nurse should instruct the client to:
- A. Take insulin at 2:00 PM each day
- B. Engage in physical activity daily
- C. Increase the dose of regular insulin
- D. Eat a protein and carbohydrate snack at bedtime
Correct Answer: D
Rationale: Somogyi effect, also known as rebound hyperglycemia, occurs as a response to nighttime hypoglycemia. Eating a protein and carbohydrate snack at bedtime can help prevent this by stabilizing blood sugar levels throughout the night. Instructing the client to take insulin at 2:00 PM each day (Choice A) may not directly address the nighttime hypoglycemia concern. Engaging in physical activity daily (Choice B) is generally beneficial for diabetes management but may not specifically prevent Somogyi's effect. Increasing the dose of regular insulin (Choice C) without addressing the nighttime hypoglycemia issue can exacerbate the problem.